Every finding on record at Saint Montserrat Hospice Care, Inc

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) of Patient was met as evidenced by: --- -Hospice Agency (HA) failed to ensure an accurate comprehensive nursing assessment was conducted by the hospice licensed staff as follows:1.To ensure the Registered Nurse 1 (RN1) conducted and documented the required components of the comprehensive assessment, including the patient's height, and weight, for six of six Hospice patients reviewed, (Patient 4, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13).2. To ensure the RN 1 accurately documented for 3 of 6 sample patients (Patient 4, Patient 9 and Patient 12) meet the Local Coverage Determination (LCD) guidelines for hospice eligibility based on the documentation and supporting documents in their electronic medical record (EMR). This failure resulted in the continued certification and/or recertification of patients who are ineligible to receive the hospice benefits. Refer to L525. The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Initial & Comprehensive Assessment of patients to ensure highest quality of care are provided to patients accurately assessed to receive the hospice benefits.

Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure an accurate comprehensive nursing assessment was conducted by the hospice licensed staff as follows:To ensure the Registered Nurse 1 (RN1) conducted and documented the required components of the comprehensive assessment, including the patient's height, and weight, for six of six Hospice patients reviewed, (Patient 4, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13).2. To ensure the RN 1 accurately documented for 3 of 6 sample patients (Patient 4, Patient 9 and Patient 12) meet the Local Coverage Determination (LCD) guidelines for hospice eligibility based on the documentation and supporting documents in their electronic medical record (EMR). This failure resulted in the continued certification and/or recertification of patients who are ineligible to receive the hospice benefits. --- During a review of Patients 9’s Personal Information Record, the record that indicates patient 9’s SOC was 4/24/2024, and Resumption of care 6/8/2025, with diagnosis of metabolic encephalopathy (  and type 2 diabetes mellitus ( along-term condition in which the whole body does not use insulin ( a hormone that helps glucose (sugar) from food  enter the cells for energy) properly or produce enough insulin).During  a concurrent home visit on 7/15/2025, at  11:30 a.m., conducted with RN 1 at the assisted living facility,  RN 1 was observed attending to Patient 9. RN 1 stated to the survey team, that she does not like to interrupt the patients sleep so she really does not ake their vital signs.During a review on 7/9/2025, at 11a.m., of patient 9’s electron medical record (EMR), showed no documentation of Patient 9’s height, weight, or MAC in the initial comprehensive assessment nursing assessment completed by RN 1.  2. During a review of patients 10’s Personal Information Record, the record that indicates patient 10’s SOC was 6/24/2025, with diagnosis of Alzheimer’s ( loss of thinking, remembering, and reasoning skills).During a concurrent home visit on 7/15/2025, at 11:30 a.m., conducted with RN 1 at the assisted living facility, Patient 10 was observed sleeping in her room on a floor mat.  RN 1 stated to the survey team, that she does not like to interrupt the patients sleep so she really does not take their vital signs. RN 1 did not assess patient 10 vital signs during the observation.During a review on 7/9/2025, at 11a.m., of patient 9’s electron medical record (EMR), showed no documentation of Patient 9’s height, weight, or MAC in the initial comprehensive assessment nursing assessment completed by RN 1. 3. During a review of Patients 11’s Personal Information Record, the record that indicates patient 10’s SOC was 6/22/2025, with diagnosis of Alzheimer’s ( loss of thinking, remembering, and reasoning skills) and systolic congestive heart failure ( the heart muscle( left ventricle- is the hearts  main pumping chamber) is weakened or damaged, making it unable to contract and pump blood out to the body with the usual force.During a concurrent home visit on 7/15/2025, at 11:30 a.m., conducted with RN 1 at the assisted living facility, RN 1 was observed attending to Patient 9. RN 1 stated to the survey team, that she does not like to interrupt the patients sleep so she really does not ake their vital signs.During a review on 7/9/2025, at 11a.m., of patient 9’s electron medical record (EMR), showed no documentation of patient 9’s height, weight, or MAC in the initial comprehensive assessment nursing assessment completed by RN 1.During a review pf Patient 9's Local Coverage Determination (LCD - helps to determine wethe a patient qualifies for the hospice under   Medicare  rules, based on prognosis and clinical criteria)Hospice Determination form on 7/9/2025, indicated, Patient does not qualify per LCD Guidelines.During an interview with the HA’s DPCS on 7/10/2025, at ---, Via telephone in the HA’s conference room, She stated, “I should be overseeing the role as regards to clinical and making sure everything is in place. I will start monitoring it cause it was the old DPCS who was monitoring it. During an interview with the ADM On 7/10/2025, at 12:30 pm, in the HA’s conference room, when asked what her role was as ADM, she stated, “I I am  involved all operation all aspects of operation like attending IDG, coming to office 3 times a week and getting all admission and discharge. Problem solving, A review of the HA’s Policy and Procedure titled,” Comprehensive Assessment revised April 2013, stipulates,” a physical assessment comma including blood pressure comma temperature comma pulse comma respirations comma skin and other relative data related to pertinent physical findings and the patients terminal illness period.”The facilities failure to obtain these objective measurements upon admission hindered the ability to develop an accurate plan of care and posed a risk for medication errors, missed nutritional issues, and lack of proper monitoring of patients clinical conditions. During a concurrent home visit with RN1 on 7/8/2025, at 11:30 a.m. to 3: pm, in the Assisted Living Facility, (ALF) RN 1 was observed providing care to the hospice patients.  When asked about obtaining patient’s vital signs, RN 1 stated,” I don’t like to interrupt their sleep, so I really do not take their vital signs.” During a review on 7/9/2025, at 3p.m., of patient 11’s electron medical record (EMR), indicated there was no documentation of initial height, weight, or MAC in both the comprehensive assessment dated 6/22/2025, and RN 1’s Skilled nursing notes for the following dates: 6/28/2025, and 7/5/2025.During an interview with RN 1 via telephone in the HA’s office on 7/10/2025, at pm, RN 1 confirmed the admission weight and all Skilled visit weight were not obtained or recorded. RN 1 stated she missed taking the weight, height .During an interview with the HA’s DPCS on 7/10/2025, at ---, Via telephone in the HA’s conference room, She stated, “I should be overseeing the role as regards to clinical and making sure everything is in place. I will start monitoring it cause it was the old DPCS who was monitoring it. During an interview with the ADM On 7/10/2025, at 12:30 pm, in the HA’s conference room, when asked what her role was as ADM, she stated, “I I am  involved all operation all aspects of operation like attending IDG, coming to office 3 times a week and getting all admission and discharge and Problem solving,A review of the HA’s Policy and Procedure titled,” Comprehensive Assessment revised April 2013, stipulates,” a physical assessment comma including blood pressure comma temperature comma pulse comma respirations comma skin and other relative data related to pertinent physical findings and the patients terminal illness period.”The facilities failure to obtain these objective measurements upon admission hindered the ability to develop an accurate plan of care and posed a risk for medication errors, missed nutritional issues, and lack of proper monitoring of patients clinical conditions.        a.      During a review of Patient 4’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 3/26/2025 with a primary diagnosis of Metabolic Encephalopathy (a brain disorder caused by a chemical imbalance in the blood, that stems from an underlying illness or organ dysfunction).During a review of Patient 4’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 7/7/2025 indicated a frequency of visits order for Skilled Nurse once a week and three as needed (PRN) visits, home health aide (HA) two times a week, Medical Social Worker (MSW) once per month and one PRN visit, and Bereavement Coordinator (BC) once per month and one PRN visit.During a review of Patient 4’s clinical record titled Comprehensive Nursing Assessment, dated 3/26/2025, there was no documented evidence of Patient 4’s height and weight. Patient 4’s Comprehensive Nursing Assessment also indicated in the section Narrative and Disease Trajectory, that the patient declined in nutrition, mental and physical status due to poor by mouth (PO) intake and required hospice care for the management of, medications, disease, pain, nutrition and dietary.During a review of Patient 4’s clinical record titled Re-Cert Assessment, dated 6/23/2025, the Re-cert Assessment indicated the author was Registered Nurse 1 (RN1). Patient 4’s Re-Cert Assessment indicated there was no documented evidence of Patient 4’s height and weight assessed for recertification of care. Patient 4’s Re-Cert Assessment indicated, under the section Nutrition, if the patient had weight loss greater than 10% in the last 6 months, and RN1 documented Yes. The Re-Cert Assessment also indicated in the section Narrative and Disease Trajectory, patient still requires hospice care for the management of medications, disease symptoms, pain, monitoring nutrition and dietary and providing education.During a review of Patient 4’s clinical records titled Visit Note RN dated 6/4/2025, 6/11/2025, 6/18/2025, 6/30/2025, and 7/7/2025 indicated the author was RN1. The visit note RN dated 6/4/2025, 6/11/2025, 6/18/2025, 6/30/2025, and 7/7/2025 indicated there was no documented evidence, under sections vitals and measurements or narrative, of Patient 4’s height and weight being assessed/monitored.During a review of Patient 4’s clinical record titled POC/IDG Review dated 7/7/2025, the POC/IDG Review indicated there was no documented evidence of Patient 4’s height and weight being assessed or monitored during review and discussion of the patient’s care with the IDG.During a concurrent interview and record review on 7/10/2025 at 12:49 p.m. with the Director of Patient Care Services (DPCS), Patient 4’s Electronic Medical Record (EMR) was reviewed. Patient 4’s EMR indicated a recertification assessment dated 6/23/2025 electronically signed by RN1. Patient 4’s EMR also indicated a Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) dated 6/23/2025 indicating, Patient does not qualify per LCD guidelines. The DPCS stated that upon admitting a patient into the HA, the admitting nurse completes the comprehensive assessment and the LCD as well. The DPCS stated and confirmed that Patient 4’s LCD did indicate the patient did not qualify for hospice care based on the LCD guidelines. The DPCS stated Patient 4’s LCD is incomplete, and the admitting nurse should have communicated that with the Medical Director 1 (MD1). The DPCS stated patient 4’s LCD at this time indicates patient is not eligible for hospice care. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care, and if they are eligible providing that information in the patient’s EMR so the IDG is aware. The DPCS stated she was just given the role of DPCS recently as the previous DPCS resigned and she has recently started to review nurses’ documentation.  During a phone interview on 7/10/2025 at 1:29 p.m. with RN1, RN1 stated she was unable to come to the HA as she is sick with covid but she is available to communicate via phone call. RN1 stated she is the RN visiting nurse for the HA and does the initial assessment visits. RN1 stated after completing initial assessment visits she communicates with MD1 regarding her assessment findings and the patient’s condition, and then MD1 will review the assessment and information. RN1 stated she completes the patient’s LCD and the LCD information is based on her assessment of the patient, medical background provided by the patient or family and supporting documentation. RN1 stated supporting documentation includes H&P, lab results, imaging results, physician notes, physician orders. RN1 stated if the patient is discharged from a hospital or nursing home, RN1 will request for and review the discharge orders, H&P, medication list and progress notes. RN1 also stated if a patient is coming from home then the RN1 will ask the family for background information about the patient and request for documents like history and physical and medication list.During a concurrent interview and record review on 7/10/2025 at 1:39 p.m. with RN1, patient 4’s EMR was reviewed. Patient 4’s EMR indicated a recertification assessment dated 6/23/2025 electronically signed by RN1. Patient 4’s EMR indicated a Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) document dated 6/23/2025 indicating, Patient does not qualify per LCD guidelines. Patient 4’s EMR also indicated there was no supporting documentation that included history and physical (H&P), lab/imaging results, or physician orders. RN1 stated and confirmed she was the admitting nurse for Patient 4 and completed the recertification assessment and LCD. RN1 stated and confirmed Patient 4’s LCD indicated patient did not qualify for hospice care per LCD guidelines. RN1 stated she was not aware of Patient 4’s LCD stating the patient did not qualify for hospice. RN1 stated Patient 4’s LCD was based on the patient’s assessment and review of medical forms like the H&P. RN1 stated it is important for her to review the LCD with the MD1 to make sure it is updated, during recertification, and accurately reflects the patient’s current health status and confirm if the patient is hospice eligible. RN1 also stated and confirmed that Patient 4’s EMR did not contain her history and/or physical, or hospital records therefore, the HA did not have any evidence to support Patient 4’s documented LCD. RN1 stated she had some hospital records for Patient 4 but she keeps them in her desk at the assisted living facility because she is not aware of how to upload them. RN1 stated that keeping the patient’s clinical records with her and not uploading it onto the EMR is not good practice because the patient’s chart is incomplete and disrupts the continuity of care for the patient from the IDG.During a concurrent interview and record review on 7/10/2025 at 1:42 p.m. with RN1, Patient 4’s EMR for recertification assessment dated 6/23/2025 and skilled nurse visit notes dated 6/4/2025, 6/11/2025, 6/18/2025, 6/30/2025, and 7/7/2025 were reviewed. RN1 stated and confirmed that the recertification assessment dated 6/23/2025 and the skilled nurse visit notes dated 6/4/2025, 6/11/2025, 6/18/2025, 6/30/2025, and 7/7/2025 did not have documentation of Patient 4’s height and weight. RN 1 stated the height and weight of the patient should be documented in the vital sign section of the assessment and notes. RN1 stated the height and weight should be obtained at initial visits and as ordered by the physician, especially for patients who have poor appetite or continue to have changes in weight. RN1 stated if the height and weight for Patient 4 is not documented on the recertification assessment and in the visit notes then she must have missed it. RN1 stated the importance of completing the patients assessment and visit note to include current height and weight is to monitor the patient for any changes and needs and report them to the physician. e. During a review of Patient 12’s clinical record titled Personal Information, undated, a Start of Care (SOC) date of 6/11/2025 with a primary diagnosis of Fracture of unspecified part of the left clavicle sequela (break in the left collarbone due to an after effect of a disease, condition or injury).During a review of Patient 12’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 7/7/2025 indicated a frequency of visits order for Skilled Nurse once a week and three as needed (PRN) visits, home health aide (HA) two times a week, Medical Social Worker (MSW) once per month and one PRN visit, and Spiritual Coordinator (SC) once per month and one PRN visit.During a review of Patient 12’s clinical record titled Comprehensive Nursing Assessment dated 6/11/2025, the comprehensive nursing assessment indicated the author was Registered Nurse 1 (RN1). Patient 12’s Comprehensive nursing assessment indicated there was no documented evidence of Patient 12’s height and weight being assessed or monitored. Patient 12’s Comprehensive Nursing Assessment also indicated, under the section Nutrition, if the patient had weight loss greater than 10% in the last 6 months, and RN1 documented Yes.During a review of Patient 12’s clinical records titled Visit Note RN dated 6/18/2025, 6/25/2025, and 7/2/2025 indicated the author was RN1. The visit notes RN dated 6/18/2025, 6/25/2025, and 7/2/2025 indicated there was no documented evidence, under the section’s vitals and measurements or narrative, of Patient 12’s height and weight being assessed or monitored.During a review of Patient 12’s clinical record titled POC/IDG Review dated 7/7/2025, the POC/IDG Review indicated there was no documented evidence of Patient 12’s height and weight being assessed or monitored during review and discussion of the patient’s care with the IDG.During a joint home visit on 7/8/2025 at 11:35 a.m. at Patient 12’s residence at the assisted living facility with RN1, Patient 12 was observed laying on her mattress, mattress not on a bed frame on the floor with gym matts surrounding the mattress, sleeping with eyes closed and respirations even and unlabored in rhythm. RN1 stated Patient 12 prefers her mattress to be off the bed rail and lower to the floor. RN1 stated Patient 12 has episodes of agitation, that is one reason why her son has not come to see her lately because once he leaves she gets upset and agitated. RN1 stated due to behavior, RN1 does not like to wake up Patient 12 if she is sleeping. RN1 stated she will let Patient 12 continue sleeping and will check on her again before lunch comes out. RN1 stated Patient 12 had already taken her medication earlier in the morning.During a concurrent interview and record review on 7/10/2025 at 12:56 p.m. with the DPCS, Patient 12’s EMR was reviewed. Patient 12’s EMR indicated a Comprehensive nursing assessment dated 6/11/2025 electronically signed by RN1. Patient 12’s EMR also indicated a Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) dated 6/11/2025 indicating Patient does not qualify per LCD guidelines. The DPCS stated that RN1 who did the initial comprehensive assessment also was to complete the LCD. The DPCS stated and confirmed that Patient 12’s LCD did indicate the patient did not qualify for hospice care based on the LCD guidelines. The DPCS stated Patient 12’s LCD is incomplete, and RN1 should have communicated that with the Medical Director 1 (MD1). The DPCS stated patient 12’s LCD at this time indicates patient is not eligible for hospice care. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care and also provide that information to the IDG. The DPCS stated she was just given the role of DPCS recently as the previous DPCS resigned and she has recently started to review nurses’ documentation.  During a concurrent interview and record review on 7/10/2025 at 1:44 p.m. with RN1, Patient 12’s EMR was reviewed. Patient 12’s EMR indicated a comprehensive nursing assessment dated 6/11/2025 electronically signed by RN1. Patient 12’s EMR indicated a Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) document dated 6/11/2025 indicating, Patient does not qualify per LCD guidelines. Patient 12’s EMR also indicated there was no supporting documentation that included history and physical (H&P), lab/imaging results, or physician orders. RN1 stated and confirmed she admitted Patient 12 and completed the comprehensive assessment and LCD. RN1 stated and confirmed Patient 12’s LCD indicated patient did not qualify for hospice care per LCD guidelines and  stated she was not aware the LCD stated the patient did not qualify for hospice. RN1 stated Patient 12’s LCD was based on the patient’s physical assessment and review of medical forms like the H&P and physician notes. RN1 stated it is important for her to review the LCD along with the MD1 to make sure it is accurate and reflects the patient’s current health status and confirm if the patient is hospice eligible. RN1 also stated and confirmed that Patient 12’s EMR did not contain her history and/or physical, or hospital records therefore, the HA did not have any evidence to support Patient 4’s documented LCD. RN1 stated Patient 12’s EMR did not have any supporting documentation because she has some hospital records for Patient 12 in her desk at the assisted living facility because she is not aware of how to upload them. RN1 stated that keeping the patient’s clinical records with her and not uploading it onto the EMR is not good practice because the patient’s chart is incomplete and disrupts the continuity of care from the IDG.During a concurrent interview and record review on 7/10/2025 at 1:47 p.m. with RN1, Patient 12’s EMR for comprehensive assessment dated 6/11/2025 and skilled nurse visit notes dated 6/18/2025, 6/25/2025, and 7/2/2025 were reviewed. RN1 stated and confirmed that the assessment dated 6/11/2025 and the skilled nurse visit notes dated 6/18/2025, 6/25/2025, and 7/2/2025 did not have documentation of Patient 12’s height and weight. RN1 stated the height and weight of the patient should be documented in the vital sign section of the assessment and notes. RN1 stated the height and weight should be obtained at initial visits and as ordered by the physician, especially for patients who have poor appetite or continue to have changes in weight. RN1 stated if the height and weight for Patient 12 is not documented on the assessment and in the visit notes then she must have missed it. RN1 stated the importance of completing the patients assessment and visit note to include current height and weight is to monitor the patient for any changes and needs and report them to the physician.  f. During a review of Patient 13’s clinical record titled Personal Information, undated indicated a Start of Care (SOC) date of 6/17/2025 with a primary diagnosis of Acute on chronic diastolic heart failure (a stiff left heart that does not relax properly between heartbeats and causes decreased blood flow and other complications).During a review of Patient 13’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 7/7/2025 indicated a frequency of visits order for Skilled Nurse once a week and three as needed (PRN) visits, home health aide (HA) two times a week, Medical Social Worker (MSW) once per month and one PRN visit, and Bereavement Coordinator (SC) once per month and one PRN visit.During a review of Patient 13’s clinical record titled Comprehensive Nursing Assessment dated 6/17/2025, the comprehensive nursing assessment indicated the author was RN1. Patient 13’s Comprehensive nursing assessment indicated there was no documented evidence of Patient 13’s height and weight being assessed or monitored. Patient 13’s Comprehensive Nursing Assessment also indicated the patient required hospice care for the management of medications, disease symptoms, pain, nutrition and dietary and continued education to the patient and family/caregiver. During a review of Patient 13’s clinical records titled Visit Note RN dated 6/24/2025, 7/1/2025 and 7/8/2025 indicated the author was RN1. The visit notes RN dated 6/24/2025, 7/1/2025 and 7/8/2025 indicated there was no documented evidence, under the section’s vitals and measurements or narrative, of Patient 13’s height and weight being assessed or monitored.During a review of Patient 13’s clinical record titled POC/IDG Review dated 7/7/2025, the POC/IDG Review indicated there was no documented evidence of Patient 13’s height and weight being assessed or monitored during review and discussion of the patient’s care with the IDG.During a joint home visit on 7/8/2025 at 11:24 a.m. at Patient 13’s residence at the assisted living facility with RN1, Patient 13 was observed laying in bed on her back, eyes closed, with feet of the bed elevated, non-verbal but responds to verbal and tactile (touch) stimulus. RN1 stated Patient 13 was sleeping at this time. RN1 was observed talking to Patient 13 in Korean language and Patient 13 would not verbally respond back but open her eyes and look at RN1.During a concurrent interview and record review on 7/10/2025 at 1:10 p.m. with the DPCS, Patient 13’s EMR was reviewed. Patient 13’s EMR indicated a Comprehensive nursing assessment dated 6/17/2025 electronically signed by RN1. Patient 13’s EMR also indicated a Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) dated 6/17/2025 asking on number 1c. if the patient optimally treated for heart disease with diuretics (a medication or substance that helps the body eliminate excess salt and water through urine) and vasodilators (a medication or substance that widens blood vessels, improving blood flow and reducing blood pressure), asked on number 2a. if the Congestive heart failure (CHF, condition where the heart muscle is unable to pump enough blood to meet the body's needs) or angina (chest pain) patient meet the criteria for New York Heart Association (NYHA) Class IV level (heart failure indicates severe limitations and symptoms even at rest) , both of which RN1 responded with a documented Yes. The DPCS stated that RN1, who did the initial comprehensive assessment, also completed the LCD. The DPCS stated and confirmed that RN1 documented a response of Yes to questions, if the patient was optimally treated for heart disease with diuretics and vasodilators and if the CHF or angina patient met the criteria for NYHA Class IV level. The DPCS stated a Yes response to those questions meant that RN1 reviewed the patient’s current medications, assessed the patient for symptoms of heart failure and reviewed other medical documents like lab results, imaging or H&P to verify the diagnosis. The DPCS stated and confirmed Patient 13’s EMR did not include supporting medical documents like what she mentioned, that supported the LCD criteria that was documented by RN1. The DPCS stated she was not aware if the HA had the supporting medical documents for the patient. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care and also provide that information to the IDG. The DPCS stated she was just given the role of DPCS recently as the previous DPCS resigned and she has recently started to review nurses’ documentation.  During a concurrent interview and record review on 7/10/2025 at 1:50 p.m. with RN1, Patient 13’s EMR was reviewed. Patient 13’s EMR indicated a comprehensive nursing assessment dated 6/17/2025 electronically signed by RN1. Patient 13’s EMR indicated an LCD document dated 6/17/2025 asking on number 1c. if the patient optimally treated for heart disease with diuretics and vasodilators and asked on number 2a. if the CHF or angina patient meet the criteria for NYHA Class IV level, both of which RN1 responded with a documented Yes. Patient 13’s EMR also indicated there was no supporting medical documentation that included history and physical (H&P), lab/imaging results, or physician orders/notes. RN1 stated and confirmed she admitted Patient 13 and completed the comprehensive assessment and LCD. RN1 stated Patient 13’s LCD was based on the patient’s physical assessment, medication list and any documents from the physician or hospital records. RN1 stated she then reviews her assessment and information she gathered to the MD1 for admission. RN1 also stated and confirmed that Patient 13’s EMR did not contain her H&P, or hospital/physician records therefore, the HA did not have any evidence to support Patient 13’s documented LCD. RN1 stated Patient 13’s EMR did not have any supporting documentation because she has some of those records for Patient 13 in her desk at the assisted living facility because she does not know how to upload them. RN1 stated that keeping the patient’s clinical records with her and not uploading it onto the EMR is not good practice because the patient’s chart is incomplete and disrupts the continuity of care from the IDG.During a concurrent interview and record review on 7/10/2025 at 1:54 p.m. with RN1, Patient 13’s EMR for comprehensive assessment dated 6/17/2025 and skilled nurse visit notes dated 6/24/2025, 7/1/2025 and 7/8/2025 were reviewed. RN1 stated and confirmed that the recertification assessment dated 6/17/2025 and the skilled nurse visit notes dated 6/24/2025, 7/1/2025 and 7/8/2025 did not have documentation of Patient 13’s height and weight. RN 1 stated the height and weight of the patient should be documented in the vital sign section of the assessment and notes. RN1 stated the height and weight should be obtained at initial visits and as ordered by the physician, especially for patient 13 with heart failure. RN1 stated if the height and weight for Patient 13 is not documented on the assessment and in the visit notes then she must have missed it. RN1 stated the importance of completing patient 13’s assessment and visit note to include current height and weight is to monitor the patient for any changes in their disease and monitor for decline or improvement in health.During a concurrent interview and record review on 7/10/2025 at 2 p.m. with RN1, Patient 13’s medical list was reviewed. Patient 13’s medication list indicated an order for medications, Digoxin (medication used to treat certain heart conditions, primarily heart failure and abnormal heart rhythms)  0.125 milligrams (mg) tablet take 1 tablet orally daily for the indication of CHF, and Furosemide (medication know as water pill that helps the body get rid of extra fluid and salt by increasing urination) 20mg tablet take 1 tablet orally daily for the indication of CHF. RN1 stated and confirmed those were the only two medications that Patient 13 was currently on for CHF. RN1 stated from the two medications listed, Furosemide is a diuretic medication. RN1 stated and confirmed Patient 13 is not on a vasodilator, therefore Patient 13 does not qualify for a Yes response on the LCD criteria when asked of she was being treated with diuretics and vasodilators. During a review of the HA's Policy and Procedure (P&P) titled Ongoing Comprehensive Assessments with a revised date of April 2013, the P&P indicated the scope and intensity of ongoing hospice patient assessments will be determined by the patient's prognosis, diagnosis, condition, desire for care, response to previous care, and the care setting. The P&P also indicated that the nurse will assess the patient on each visit for vital signs appropriate to the patient's condition.

Based on observation, interview and record review the Hospice Agency (HA) failed to follow standards of practice, and their policy and procedure related to maintaining a clean dry surface to place their nursing bag that contained hand washing equipment, assessment equipment, disposable supplies, paper supplies and/or laptop or documentation device used every patient's home visit for three out of six sampled patients (Patient 10, Patient 11, and Patient 13). This failure had the potential to place the patients at risk of acquiring infection as a result of cross-contamination. --- During a review of patients 10’s Personal Information Record, the record that indicates patient 10’s SOC was 6/24/2025, with diagnosis of Alzheimer’s (loss of thinking, remembering, and reasoning skills).During a joint home visit on 7/8/2025 at 10:50 a.m., at Patient 10’s residence at the Assisted Living Facility with Registered Nurse 1 (RN1), Patient 10 was observed lying in her bed on her back side, with eyes closed, non-verbal but responded by opening her eyes to RN1’s voice and/or touch. RN1 was observed carrying her vital sign equipment, of blood pressure cuff machine, thermometer, and pulse oximeter in a plastic rectangular basket. RN1 was observed not setting up a clean field, once in the patient’s room, for the basket with her equipment. RN1 was observed placing the plastic rectangular basket of her equipment on Patient 10’s bedside table without cleaning the area or basket and did not place a protective barrier underneath the basket. During a review of Patients 11’s Personal Information Record, the record that indicates patient 10’s SOC was 6/22/2025, with diagnosis of Alzheimer’s (loss of thinking, remembering, and reasoning skills) and systolic congestive heart failure (the heart muscle( left ventricle- is the hearts  main pumping chamber) is weakened or damaged, making it unable to contract and pump blood out to the body with the usual force).During a joint home visit on 7/8/2025 at 11:05 a.m. at Patient 11’s resident at the Assisted Living Facility with RN1, Patient 11 was observed laying on the hospital bed, on an air mattress with eyes closed and on nasal cannula (a small plastic tube, which fits into the person’s nostrils for providing supplemental oxygen) connected to oxygen concentrator (a medical device that provides a continuous supply of oxygen to individuals who require supplemental oxygen therapy) at flow rate of 2 liters/minute (L/min.- unit of volume/unit of time, the amount of oxygen flow into the patient’s nostrils every minute). RN1 was observed carrying her vital signs equipment, of blood pressure cuff machine, thermometer, and pulse oximeter in a plastic rectangular basket. RN1 was observed not setting up a clean field, once in the patient’s room, for the basket with her equipment. RN1 was observed placing the plastic rectangular basket of her equipment on the patient’s bedside table without cleaning the area or basket and did not place a protective barrier underneath the basket. During a review of Patient 13’s clinical record titled Personal Information, undated indicated a Start of Care (SOC) date of 6/17/2025 with a primary diagnosis of Acute on chronic diastolic heart failure (a stiff left heart that does not relax properly between heartbeats and causes decreased blood flow and other complications).During a joint home visit on 7/8/2025 at 11:24 a.m. at Patient 13’s residence at the assisted living facility with RN1, Patient 13 was observed lying in bed on her back, eyes closed, with feet of the bed elevated, non-verbal but responds to verbal and tactile (touch) stimulus. RN1 stated Patient 13 was sleeping at this time. RN1 was observed talking to Patient 13 in Korean language and Patient 13 would not verbally respond back but open her eyes and look at RN1. RN1 was observed carrying her vital sign equipment, of blood pressure cuff machine, thermometer, and pulse oximeter in a plastic rectangular basket. RN1 was observed not setting up a clean field, once in the patient’s room, for the basket with her equipment. RN1 was observed placing the plastic rectangular basket of her equipment on the patient’s bedside table without cleaning the area or basket and did not place a protective barrier underneath the basket.During an interview on 7/10/2025 at 2:15 p.m., with the Administrator (ADM), the ADM stated the HA policy for bag technique is that each field nurse maintains a bag with their equipment and supplies and in between each patient home visit, the field nurse is to clean the bag and equipment and set out a clean area to place them on, to prevent infection. ADM stated RN1 called her after the home visits were completed and told her that she (RN1) was nervous during the visits with the patients and placed her equipment in a basket not a bag and forgot to provide a clean area for her basket and equipment and forgot to wipe it down between each patient. During a review of the HA’s Policy and Procedures (P&P) titled Bag Technique, with a revised date of April 2012, the P&P indicated that the nurse will have the following contents in the nursing bag; hand washing equipment, assessment equipment, disposable supplies, paper supplies and/or laptop or documentation device. The P&P also indicated that the bag will be placed on a clean dry surface in the home and the bag will contain a designated clean and dirty area, and when visits is complete reusable equipment will be cleaned using alcohol and/or soap and water as appropriate and will be returned to the bag.

Based on observation, interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure staff must submit completed nursing visit notes and assessments that reflected the patients current health status for six out of six sampled patients (Patient 4, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13).   This failure resulted in incomplete and inaccurate clinical records for Patient 4, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13, that could lead to misinformation and non-continuity of care and services provided to the patient. --- -During a review of Patients 9’s Personal Information Record indicated Patient 9’s SOC was 4/24/2024, and Resumption of care 6/8/2025, with diagnosis of metabolic encephalopathy (  and type 2 diabetes mellitus ( along-term condition in which the whole body does not use insulin ( a hormone that helps glucose (sugar) from food  enter the cells for energy) properly or produce enough insulin).During a concurrent home visit on 7/15/2025, at 11:30 a.m., conducted with RN 1 at the assisted living facility, RN 1 was observed attending to Patient 9. RN 1 stated to the survey team, that she does not like to interrupt the patients sleep so she really does not take their vital signs.During a review on 7/9/2025, at 11a.m., of Patient 9’s electron medical record (EMR), showed no documentation of Patient 9’s height, weight, or MAC in the initial comprehensive assessment nursing assessment was completed by RN 1.  -During a review of patients 10’s Personal Information Record, the record that indicates patient 10’s SOC was 6/24/2025, with diagnosis of Alzheimer’s (loss of thinking, remembering, and reasoning skills).During a concurrent home visit on 7/15/2025, at 11:30 a.m., conducted with RN 1 at the assisted living facility, Patient 10 was observed sleeping in her room on a floor mat.  RN 1 stated to the survey team, that she does not like to interrupt the patients sleep so she really does not take their vital signs. RN 1 did not assess Patient 10 vital signs during the observation.During a review on 7/9/2025, at 11a.m., of Patient 9’s electronic medical record (EMR), showed no documentation of Patient 9’s height, weight, or MAC in the initial comprehensive assessment nursing assessment completed by RN 1. -During a review of Patients 11’s Personal Information Record, the record that indicates Patient 10’s SOC was 6/22/2025, with diagnoses of Alzheimer’s ( loss of thinking, remembering, and reasoning skills) and systolic congestive heart failure ( the heart muscle( left ventricle- is the hearts  main pumping chamber) is weakened or damaged, making it unable to contract and pump blood out to the body with the usual force.During a concurrent home visit on 7/15/2025, at 11:30 a.m., conducted with RN 1 at the assisted living facility, RN 1 was observed attending to Patient 9. RN 1 stated to the survey team, that she does not like to interrupt the patients sleep so she really does not take their vital signs.During a review on 7/9/2025, at 11a.m., of Patient 9’s electron medical record (EMR), showed no documentation of patient 9’s height, weight, or MAC in the initial comprehensive assessment nursing assessment completed by RN 1.During a review pf Patient 9's Local Coverage Determination (LCD - helps to determine wither a patient qualifies for the hospice under Medicare rules, based on prognosis and clinical criteria) Hospice Determination form on 7/9/2025, indicated, Patient does not qualify per LCD Guidelines.During an interview with the HA’s DPCS on 7/10/2025, via telephone in the HA’s conference room, she stated, “I should be overseeing the role as regards to clinical and making sure everything is in place. I will start monitoring it because it was the old DPCS who was monitoring it.During an interview with the ADM On 7/10/2025, at 12:30 pm, in the HA’s conference room, when asked what her role was as ADM, she stated, “I am involved in operation all aspects of operation like attending IDG, coming to office 3 times a week and getting all admission and discharge and problem solving,During a concurrent home visit with RN1 on 7/8/2025, at 11:30 a.m. to 3: pm, in the Assisted Living Facility, (ALF) RN 1 was observed providing care to the hospice patients.  When asked about obtaining patient’s vital signs, RN 1 stated,” I don’t like to interrupt their sleep, so I really do not take their vital signs.”During a review on 7/9/2025, at 3p.m., of Patient 11’s electron medical record (EMR), indicated there was no documentation of initial height, weight, or MAC in both the comprehensive assessment dated 6/22/2025, and RN 1’s Skilled nursing notes for the following dates: 6/28/2025, and 7/5/2025.During an interview with RN 1 via telephone in the HA’s office on 7/10/2025, at pm, RN 1 confirmed the admission weight, and all Skilled visit weight were not obtained or recorded. RN 1 stated she missed taking the weight, height.During an interview with the HA’s DPCS on 7/10/2025,  via telephone in the HA’s conference room, stated, “I should be overseeing the role as regards to clinical and making sure everything is in place. I will start monitoring it because it was the old DPCS who was monitoring it.During an interview with the ADM On 7/10/2025, at 12:30 pm, in the HA’s conference room, when asked what her role was as ADM, she stated, “I am  involved in all operation aspects like attending IDG, coming to office 3 times a week and getting all admission and discharge and problem solving. A review of the HA’s Policy and Procedure titled,” Comprehensive Assessment revised April 2013, stipulates,” a physical assessment comma including blood pressure comma temperature comma pulse comma respirations comma skin and other relative data related to pertinent physical findings and the patient's terminal illness period. "The facilities failure to obtain these objective measurements upon admission hindered the ability to develop an accurate plan of care and posed a risk for medication errors, missed nutritional issues, and lack of proper monitoring of patients' clinical conditions. A review of the HA’s job description title executive clinical director of patient care services indicated the Clinical Director/Director of Patient Care Services is responsible for the overall direction of the Hospice clinical services. The Clinical Director/ Director of Patient Care Services establishes implements and evaluates goals and objectives for hospital services that meet and promote the standards of quality and contribute to the total organization and philosophy. The Clinical Director assists clinical supervisor slash nursing supervisors in managing clinical teams and planning. Overseas the maintenance of patients' clinical records statistics reports and records for purpose of evaluating and reporting of organizational activities.         - During a review of Patient 4’s clinical record titled Personal Information, undated, indicated a Start of Care (SOC) date of 3/26/2025 with a primary diagnosis of Metabolic Encephalopathy (a brain disorder caused by a chemical imbalance in the blood, that stems from an underlying illness or organ dysfunction).During a review of Patient 4’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 7/7/2025 indicated a frequency of visits order for Skilled Nurse once a week and three as needed (PRN) visits, home health aide (HA) two times a week, Medical Social Worker (MSW) once per month and one PRN visit, and Bereavement Coordinator (BC) once per month and one PRN visit.During a review of Patient 4’s clinical record titled Comprehensive Nursing Assessment, dated 3/26/2025, there was no documented evidence of Patient 4’s height and weight. Patient 4’s Comprehensive Nursing Assessment also indicated in the section Narrative and Disease Trajectory, that the patient declined in nutrition, mental and physical status due to poor by mouth (PO) intake and required hospice care for the management of, medications, disease, pain, nutrition and dietary.During a review of Patient 4’s clinical record titled Re-Cert Assessment, dated 6/23/2025, the Re-cert Assessment indicated the author was Registered Nurse 1 (RN1). Patient 4’s Re-Cert Assessment indicated there was no documented evidence of Patient 4’s height and weight assessed for recertification of care. Patient 4’s Re-Cert Assessment indicated, under the section Nutrition, if the patient had weight loss greater than 10% in the last 6 months, and RN1 documented Yes. The Re-Cert Assessment also indicated in the section Narrative and Disease Trajectory, patient still requires hospice care for the management of medications, disease symptoms, pain, monitoring nutrition and dietary and providing education.During a review of Patient 4’s clinical records titled Visit Note RN dated 6/4/2025, 6/11/2025, 6/18/2025, 6/30/2025, and 7/7/2025 indicated the author was RN1. The RN visit notes dated 6/4/2025, 6/11/2025, 6/18/2025, 6/30/2025, and 7/7/2025 indicated no documented evidence, under sections vitals and measurements or narrative, of Patient 4’s height and weight being assessed/monitored.During a review of Patient 4’s clinical record titled POC/IDG Review dated 7/7/2025, the POC/IDG Review indicated there was no documented evidence of Patient 4’s height and weight being assessed or monitored during review and discussion of the patient’s care with the IDG.During a concurrent interview and record review on 7/10/2025 at 12:49 p.m., with the Director of Patient Care Services (DPCS), Patient 4’s Electronic Medical Record (EMR) was reviewed. Patient 4’s EMR indicated a recertification assessment dated 6/23/2025 electronically signed by RN1. Patient 4’s EMR also indicated a Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) dated 6/23/2025 indicating, Patient does not qualify per LCD guidelines. The DPCS stated that upon admitting a patient into the HA, the admitting nurse completes the comprehensive assessment and the LCD as well. The DPCS stated and confirmed that Patient 4’s LCD did indicate the patient did not qualify for hospice care based on the LCD guidelines. The DPCS stated Patient 4’s LCD is incomplete, and the admitting nurse should have communicated that with the Medical Director 1 (MD1). The DPCS stated Patient 4’s LCD at this time indicates patient is not eligible for hospice care. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care, and if they are eligible providing that information in the patient’s EMR so the IDG is aware. The DPCS stated she was just given the role of DPCS recently as the previous DPCS resigned and she has recently started to review nurses’ documentation.  During a phone interview on 7/10/2025 at 1:29 p.m., with RN1 stated she was unable to come to the HA as she was sick with COVID but she was available to communicate via phone call. RN1 stated she was the RN visiting nurse for the HA and does the initial assessment visits. RN1 stated after completing initial assessment visits she communicates with MD1 regarding her assessment findings and the patient’s condition, and then MD1 will review the assessment and information. RN1 stated she completed the patient’s LCD and the LCD information is based on her assessment of the patient, medical background provided by the patient or family and supporting documentation. RN1 stated supporting documentation includes H&P, lab results, imaging results, physician notes, physician orders. RN1 stated if the patient is discharged from a hospital or nursing home, RN1 will request for and review the discharge orders, H&P, medication list and progress notes. RN1 also stated if a patient is coming from home then the RN1 will ask the family for background information about the patient and request for documents like history and physical and medication list.During a concurrent interview and record review on 7/10/2025 at 1:39 p.m., with RN1, Patient 4’s EMR was reviewed. Patient 4’s EMR indicated a recertification assessment dated 6/23/2025 electronically signed by RN1. Patient 4’s EMR indicated a Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) document dated 6/23/2025 indicating, Patient 4 does not qualify per LCD guidelines. Patient 4’s EMR also indicated there was no supporting documentation that included history and physical (H&P), lab/imaging results, or physician orders. RN1 stated and confirmed she was the admitting nurse for Patient 4 and completed the recertification assessment and LCD. RN1 stated and confirmed Patient 4’s LCD indicated patient did not qualify for hospice care per LCD guidelines. RN1 stated she was not aware of Patient 4’s LCD stating the patient did not qualify for hospice. RN1 stated Patient 4’s LCD was based on the patient’s assessment and review of medical forms like the H&P. RN1 stated it is important for her to review the LCD with the MD1 to make sure it is updated, during recertification, and accurately reflects the patient’s current health status and confirm if the patient is hospice eligible. RN1 also stated and confirmed that Patient 4’s EMR did not contain her history and/or physical, or hospital records therefore, the HA did not have any evidence to support Patient 4’s documented LCD. RN1 stated she had some hospital records for Patient 4 but she keeps them in her desk at the assisted living facility because she is not aware of how to upload them. RN1 stated that keeping the patient’s clinical records with her and not uploading it onto the EMR is not good practice because the patient’s chart is incomplete and disrupts the continuity of care for the patient from the IDG.During a concurrent interview and record review on 7/10/2025 at 1:42 p.m. with RN1, Patient 4’s EMR for recertification assessment dated 6/23/2025 and skilled nurse visit notes dated 6/4/2025, 6/11/2025, 6/18/2025, 6/30/2025, and 7/7/2025 were reviewed. RN1 stated and confirmed that the recertification assessment dated 6/23/2025 and the skilled nurse visit notes dated 6/4/2025, 6/11/2025, 6/18/2025, 6/30/2025, and 7/7/2025 did not have documentation of Patient 4’s height and weight. RN 1 stated the height and weight of the patient should be documented in the vital sign section of the assessment and notes. RN1 stated the height and weight should be obtained at initial visits and as ordered by the physician, especially for patients who have poor appetite or continue to have changes in weight. RN1 stated if the height and weight for Patient 4 were not documented on the recertification assessment and in the visit notes then she must have missed it. RN1 stated the importance of completing the patient's assessment and visit note to include current height and weight is to monitor the patient for any changes and needs and report them to the physician.           - During a review of Patient 12’s clinical record titled Personal Information, undated, a Start of Care (SOC) date of 6/11/2025 with a primary diagnosis of Fracture of unspecified part of the left clavicle sequela (break in the left collarbone due to an after effect of a disease, condition or injury).During a review of Patient 12’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 7/7/2025 indicated a frequency of visits order for Skilled Nurse once a week and three as needed (PRN) visits, home health aide (HA) two times a week, Medical Social Worker (MSW) once per month and one PRN visit, and Spiritual Coordinator (SC) once per month and one PRN visit.During a review of Patient 12’s clinical record titled Comprehensive Nursing Assessment dated 6/11/2025, the comprehensive nursing assessment indicated the author was Registered Nurse 1 (RN1). Patient 12’s Comprehensive nursing assessment indicated there was no documented evidence of Patient 12’s height and weight being assessed or monitored. Patient 12’s Comprehensive Nursing Assessment also indicated, under the section Nutrition, if the patient had weight loss greater than 10% in the last 6 months, and RN1 documented Yes.During a review of Patient 12’s clinical records titled Visit Note RN dated 6/18/2025, 6/25/2025, and 7/2/2025 indicated the author was RN1. The visit notes RN dated 6/18/2025, 6/25/2025, and 7/2/2025 indicated there was no documented evidence, under the section’s vitals and measurements or narrative, of Patient 12’s height and weight being assessed or monitored.During a review of Patient 12’s clinical record titled POC/IDG Review dated 7/7/2025, the POC/IDG Review indicated there was no documented evidence of Patient 12’s height and weight being assessed or monitored during review and discussion of the patient’s care with the IDG.During a joint home visit on 7/8/2025 at 11:35 a.m., at Patient 12’s residence at the assisted living facility with RN1, Patient 12 was observed laying on her mattress, mattress not on a bed frame on the floor with gym matts surrounding the mattress, sleeping with eyes closed and respirations even and unlabored in rhythm. RN1 stated Patient 12 prefers her mattress to be off the bed rail and lower to the floor. RN1 stated Patient 12 has episodes of agitation, that is one reason why her son has not come to see her lately because once he leaves, she gets upset and agitated. RN1 stated due to behavior, RN1 does not like to wake up Patient 12 if she is sleeping. RN1 stated she will let Patient 12 continue sleeping and will check on her again before lunch comes out. RN1 stated Patient 12 had already taken her medication earlier in the morning.During a concurrent interview and record review on 7/10/2025 at 12:56 p.m., with the DPCS, Patient 12’s EMR was reviewed. Patient 12’s EMR indicated a Comprehensive nursing assessment dated 6/11/2025 electronically signed by RN1. Patient 12’s EMR also indicated a Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) dated 6/11/2025 indicating Patient does not qualify per LCD guidelines. The DPCS stated that RN1 who did the initial comprehensive assessment also was to complete the LCD. The DPCS stated and confirmed that Patient 12’s LCD did indicate the patient did not qualify for hospice care based on the LCD guidelines. The DPCS stated Patient 12’s LCD is incomplete, and RN1 should have communicated that with the Medical Director 1 (MD1). The DPCS stated patient 12’s LCD at this time indicates patient is not eligible for hospice care. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care and also provide that information to the IDG. The DPCS stated she was just given the role of DPCS recently as the previous DPCS resigned and she has recently started to review nurses’ documentation.  During a concurrent interview and record review on 7/10/2025 at 1:44 p.m., with RN1, Patient 12’s EMR was reviewed. Patient 12’s EMR indicated a comprehensive nursing assessment dated 6/11/2025 electronically signed by RN1. Patient 12’s EMR indicated a Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) document dated 6/11/2025 indicating, Patient does not qualify per LCD guidelines. Patient 12’s EMR also indicated there was no supporting documentation that included history and physical (H&P), lab/imaging results, or physician orders. RN1 stated and confirmed she admitted Patient 12 and completed the comprehensive assessment and LCD. RN1 stated and confirmed Patient 12’s LCD indicated patient did not qualify for hospice care per LCD guidelines and  stated she was not aware the LCD stated the patient did not qualify for hospice. RN1 stated Patient 12’s LCD was based on the patient’s physical assessment and review of medical forms like the H&P and physician notes. RN1 stated it is important for her to review the LCD along with the MD1 to make sure it is accurate and reflects the patient’s current health status and confirm if the patient is hospice eligible. RN1 also stated and confirmed that Patient 12’s EMR did not contain her history and/or physical, or hospital records therefore, the HA did not have any evidence to support Patient 4’s documented LCD. RN1 stated Patient 12’s EMR did not have any supporting documentation because she has some hospital records for Patient 12 in her desk at the assisted living facility because she is not aware of how to upload them. RN1 stated that keeping the patient’s clinical records with her and not uploading it onto the EMR is not good practice because the patient’s chart is incomplete and disrupts the continuity of care from the IDG.During a concurrent interview and record review on 7/10/2025 at 1:47 p.m. with RN1, Patient 12’s EMR for comprehensive assessment dated 6/11/2025 and skilled nurse visit notes dated 6/18/2025, 6/25/2025, and 7/2/2025 were reviewed. RN1 stated and confirmed that the assessment dated 6/11/2025 and the skilled nurse visit notes dated 6/18/2025, 6/25/2025, and 7/2/2025 did not have documentation of Patient 12’s height and weight. RN1 stated the height and weight of the patient should be documented in the vital sign section of the assessment and notes. RN1 stated the height and weight should be obtained at initial visits and as ordered by the physician, especially for patients who have poor appetite or continue to have changes in weight. RN1 stated if the height and weight for Patient 12 is not documented on the assessment and in the visit notes then she must have missed it. RN1 stated the importance of completing the patients assessment and visit note to include current height and weight is to monitor the patient for any changes and needs and report them to the physician.       - During a review of Patient 13’s clinical record titled Personal Information, undated indicated a Start of Care (SOC) date of 6/17/2025 with a primary diagnosis of Acute on chronic diastolic heart failure (a stiff left heart that does not relax properly between heartbeats and causes decreased blood flow and other complications).During a review of Patient 13’s clinical record titled Plan of Care/Interdisciplinary Group (POC/IDG) Review dated 7/7/2025 indicated a frequency of visits order for Skilled Nurse once a week and three as needed (PRN) visits, home health aide (HA) two times a week, Medical Social Worker (MSW) once per month and one PRN visit, and Bereavement Coordinator (SC) once per month and one PRN visit.During a review of Patient 13’s clinical record titled Comprehensive Nursing Assessment dated 6/17/2025, the comprehensive nursing assessment indicated the author was RN1. Patient 13’s Comprehensive nursing assessment indicated there was no documented evidence of Patient 13’s height and weight being assessed or monitored. Patient 13’s Comprehensive Nursing Assessment also indicated the patient required hospice care for the management of medications, disease symptoms, pain, nutrition and dietary and continued education to the patient and family/caregiver. During a review of Patient 13’s clinical records titled Visit Note RN dated 6/24/2025, 7/1/2025 and 7/8/2025 indicated the author was RN1. The visit notes RN dated 6/24/2025, 7/1/2025 and 7/8/2025 indicated there was no documented evidence, under the section’s vitals and measurements or narrative, of Patient 13’s height and weight being assessed or monitored.During a review of Patient 13’s clinical record titled POC/IDG Review dated 7/7/2025, the POC/IDG Review indicated there was no documented evidence of Patient 13’s height and weight being assessed or monitored during review and discussion of the patient’s care with the IDG.During a joint home visit on 7/8/2025 at 11:24 a.m. at Patient 13’s residence at the assisted living facility with RN1, Patient 13 was observed lying in bed on her back, eyes closed, with feet of the bed elevated, non-verbal but responds to verbal and tactile (touch) stimulus. RN1 stated Patient 13 was sleeping at this time. RN1 was observed talking to Patient 13 in Korean language and Patient 13 would not verbally respond back but open her eyes and look at RN1.During a concurrent interview and record review on 7/10/2025 at 1:10 p.m., with the DPCS, Patient 13’s EMR was reviewed. Patient 13’s EMR indicated a Comprehensive nursing assessment dated 6/17/2025 electronically signed by RN1. Patient 13’s EMR also indicated a Local Coverage Determination (LCD, guideline for determining if a patient meets the eligibility requirements for hospice care) dated 6/17/2025 asking on number 1c. if the patient optimally treated for heart disease with diuretics (a medication or substance that helps the body eliminate excess salt and water through urine) and vasodilators (a medication or substance that widens blood vessels, improving blood flow and reducing blood pressure), asked on number 2a. if the Congestive heart failure (CHF, condition where the heart muscle is unable to pump enough blood to meet the body's needs) or angina (chest pain) patient meet the criteria for New York Heart Association (NYHA) Class IV level (heart failure indicates severe limitations and symptoms even at rest) , both of which RN1 responded with a documented Yes. The DPCS stated that RN1, who did the initial comprehensive assessment, also completed the LCD. The DPCS stated and confirmed that RN1 documented a response of Yes to questions, if the patient was optimally treated for heart disease with diuretics and vasodilators and if the CHF or angina patient met the criteria for NYHA Class IV level. The DPCS stated a Yes response to those questions meant that RN1 reviewed the patient’s current medications, assessed the patient for symptoms of heart failure and reviewed other medical documents like lab results, imaging or H&P to verify the diagnosis. The DPCS stated and confirmed Patient 13’s EMR did not include supporting medical documents like what she mentioned, that supported the LCD criteria that was documented by RN1. The DPCS stated she was not aware if the HA had the supporting medical documents for the patient. The DPCS stated the importance of completing an LCD for a newly admitted patient to the HA is to verify their eligibility for hospice care and also provide that information to the IDG. The DPCS stated she was just given the role of DPCS recently as the previous DPCS resigned and she has recently started to review nurses’ documentation.  During a concurrent interview and record review on 7/10/2025 at 1:50 p.m., with RN1, Patient 13’s EMR was reviewed. Patient 13’s EMR indicated a comprehensive nursing assessment dated 6/17/2025 electronically signed by RN1. Patient 13’s EMR indicated an LCD document dated 6/17/2025 asking on number 1c. if the patient optimally treated for heart disease with diuretics and vasodilators and asked on number 2a. if the CHF or angina patient meet the criteria for NYHA Class IV level, both of which RN1 responded with a documented Yes. Patient 13’s EMR also indicated there was no supporting medical documentation that included history and physical (H&P), lab/imaging results, or physician orders/notes. RN1 stated and confirmed she admitted Patient 13 and completed the comprehensive assessment and LCD. RN1 stated Patient 13’s LCD was based on the patient’s physical assessment, medication list and any documents from the physician or hospital records. RN1 stated she then reviews her assessment and information she gathered to the MD1 for admission. RN1 also stated and confirmed that Patient 13’s EMR did not contain her H&P, or hospital/physician records therefore, the HA did not have any evidence to support Patient 13’s documented LCD. RN1 stated Patient 13’s EMR did not have any supporting documentation because she has some of those records for Patient 13 in her desk at the assisted living facility because she does not know how to upload them. RN1 stated that keeping the patient’s clinical records with her and not uploading it onto the EMR is not good practice because the patient’s chart is incomplete and disrupts the continuity of care from the IDG.During a concurrent interview and record review on 7/10/2025 at 1:54 p.m., with RN1, Patient 13’s EMR for comprehensive assessment dated 6/17/2025 and skilled nurse visit notes dated 6/24/2025, 7/1/2025 and 7/8/2025 were reviewed. RN1 stated and confirmed that the recertification assessment dated 6/17/2025 and the skilled nurse visit notes dated 6/24/2025, 7/1/2025 and 7/8/2025 did not have documentation of Patient 13’s height and weight. RN 1 stated the height and weight of the patient should be documented in the vital sign section of the assessment and notes. RN1 stated the height and weight should be obtained at initial visits and as ordered by the physician, especially for Patient 13 with heart failure. RN1 stated if the height and weight for Patient 13 is not documented on the assessment and in the visit notes then she must have missed it. RN1 stated the importance of completing Patient 13’s assessment and visit note to include current height, and weight is to monitor the patient for any changes in their disease and monitor for decline or improvement in health.During a concurrent interview and record review on 7/10/2025 at 2 p.m., with RN1, Patient 13’s medical list was reviewed. Patient 13’s medication list indicated an order for medications, Digoxin (medication used to treat certain heart conditions, primarily heart failure and abnormal heart rhythms)  0.125 milligrams (mg) tablet take 1 tablet orally daily for the indication of CHF, and Furosemide (medication know as water pill that helps the body get rid of extra fluid and salt by increasing urination) 20mg tablet take 1 tablet orally daily for the indication of CHF. RN1 stated and confirmed those were the only two medications that Patient 13 was currently on for CHF. RN1 stated from the two medications listed, Furosemide is a diuretic medication. RN1 stated and confirmed Patient 13 was not on a vasodilator, therefore Patient 13 does not qualify for a Yes response on the LCD criteria when asked if she was being treated with diuretics and vasodilators.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the condition of participation (CoP-a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Organizational Environment were met as follows: --- 1. The facility failed to ensure for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9), the Visiting Registered Nurse (VRN) coordinated patient care for assessment of the patients’ needs and implementation of the plan of care (POC, a written document that outlines the specific needs and services provided to a hospice patient and their family/caregiver) when: 1. Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting]), as ordered by the physician, were not available for the patients to use when needed.2. Patient 2’s oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, was not available for the patient to use when needed.These failures had the potential to result in significant discomfort and distress for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9, and are likely to suffer unmanaged pain or may die in severe pain or distress and agitation which can lead to emergency hospitalization that may contribute to unavoidable traumatic death. In addition, the patients are likely to experience undignified death and exposed to an unsafe environment. (Refer to L540)2. The facility failed to implement the individualized written plan of care (POC, a written document that outlines the specific needs and services provided to a hospice patient and their family/caregiver) on pain management and respiratory care for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). This failure had the potential for the patients’ needs and risks to not be addressed and may lead to increased pain, suffering, emergency hospitalization and may contribute to an avoidable traumatic death. (Refer to L543)The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (relating to rules or laws which have been formally written down) mandated compliance with the Federal regulations for Interdisciplinary Group (IDG), Care Planning (CP) , and Coordination Service to ensure provision of the highest quality of care for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9 who were assessed to receive hospice care services.

Based on observation, interview, and record review, the facility failed to ensure for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9), the Visiting Registered Nurse (VRN) coordinated patient care for assessment of the patients’ needs and implementation of the plan of care (POC, a written document that outlines the specific needs and services provided to a hospice patient and their family/caregiver) when: 1. Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting]), as ordered by the physician, were not available for the patients to use when needed.2. Patient 2’s oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, was not available for the patient to use when needed.These failures had the potential to result in significant discomfort and distress for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9, and are likely to suffer unmanaged pain or may die in severe pain or distress and agitation which can lead to emergency hospitalization that may contribute to unavoidable traumatic death. In addition, the patients are likely to experience undignified death and exposed to an unsafe environment.On 5/16/2025 at 7:46 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the Hospice Agency’s (HA- an agency that specializes in providing medical care for people who are expected to live six months or less) Visiting Registered Nurse (VRN) for failing to ensure the coordination of patient care for assessments of the patients’ needs and implementation of the plan of care.On 5/19/25 at 4:49 p.m. while on site and after verifying the implementation of the accepted IJ removal plan (IJRP- includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death of a patient likely), the survey team removed the IJ in the presence of the Administrator. --- During a record review of nine hospice patients, they had a physician’s order for comfort pack medications, intended for symptoms and pain management. The Visiting Registered Nurse (RN) failed to implement for the nine of nine patients their plan of care for pain management related to terminal illness, when the comfort packs (Morphine) were not available in their home (an assisted living facility). During record review of one of two hospice patients (Patient 2) had a physician’s order for oxygen 2-5 LPM via nasal cannula as needed for SOB. The hospice failed to ensure the availability of the physician-ordered oxygen concentrators for use and as needed basis. During an interview and observation on 5/15/2025 at 2:39 pm with Med Tech 1, Med Tech 1 stated Patient 1, Patient 2, and Patient 3’s comfort pack medications were missing. Med Tech 1 stated she does not have those medications (Morphine, Ativan, and Ondansetron) for the patients. During a concurrent observation and interview on 5/16/25 at 2:24 pm with Visiting RN, the Visiting RN stated Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications were missing and do not have those medications (Morphine, Ativan, and Ondansetron) for the patients. During a record review of the patients’ (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9) “Care Plan”, the “Care Plan” indicated the Intervention for pain was to resolve pain with medications ordered.  During a record review of Patient 2’s “Care Plan”, the “Care Plan” indicated, the Intervention for Respiratory was Oxygen as ordered via NC at 2-5 L/min as needed for shortness of breath (SOB). During an interview on 5/16/25 at 4:26 pm with the Visiting RN, the Visiting RN stated she was the one responsible for ensuring all the patients’ medications ordered by the physician, are available for administration. The RN stated she was not checking the patients’ comfort pack medications because the patients were not using it. Visiting RN stated she was the one responsible in coordinating the care and reviewing the patients’ medication during the Interdisciplinary Group (IDG) meeting. The RN stated she should present to the IDG any concern or issue with the patients’ medications including the efficacy of the treatment, new medication, and any need for change or discontinuation of the medications. The Visiting RN stated she did not discuss and consult the physician during the IDG regarding the patients’ comfort packs medication if needed to change or discontinued. During an interview on 5/16/25 at 6:13 pm with the Visiting RN, Visiting RN stated it is her responsibility to review the care plan and ensure the interventions are being implemented. The Visiting RN stated it is her responsibility to ensure Patient 2’s oxygen concentrator was available for use as needed by the patient. During a review of Patient 1’s “Personal Information”, the “Personal Information” indicated, Patient 1’s start of care (SOC) was on 10/30/2023, with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time), Alzheimer’s dementia (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do).  During a review of Patient 2’s “Personal Information”, the “Personal Information” indicated, Patient 2’s start of care (SOC) was on 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia ( a condition where there’s not enough oxygen or too much carbon dioxide in the body over time), dementia ( loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult).   During a review of Patient 3’s “Personal Information”, the “Personal Information” indicated, Patient 3’s start of care (SOC) was on 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip).  During a review of  Patient 4’s “Personal Information”, the “Personal Information” indicated, Patient 4’s SOC was on 3/26/2025, with primary diagnosis of Metabolic Encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do).  During a review of Patient 5’s “Personal Information”, the “Personal Information” indicated, Patient 5’s start of care (SOC) was on 2/21/2025, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with healed traumatic fracture (healed bone break).  During a review of Patient 6’s “Personal Information”, the “Personal Information” indicated, Patient 6’s start of care (SOC) was on 12/6/2024, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering (myelin) on nerve fibers in the brain and spinal cord).  During a review of Patient 7’s “Personal Information”, the “Personal Information” indicated, Patient 7’s start of care (SOC) was on was on 8/15/2024 with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes), Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do), dementia  (loss of thinking, remembering and reasoning skill) and chronic back/legs pain (long-term pain to back and legs).   During a review of Patient 8’s “Personal Information”, the “Personal Information” indicated, Patient 8’s start of care (SOC) was on 6/16/2024, with metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) and dementia.  During a review of Patient 9’s “Personal Information”, the “Personal Information” indicated, Patient 9’s start of care (SOC) was on 4/4/2024, with diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes), type 2 diabetes mellitus (diabetes mellitus is a long-term condition in which the body does not use insulin (a hormone that helps glucose (sugar) from food enter the cells for energy) properly or produce enough insulin.   During an interview with the ADM on 5/17/2025 at 4:15 PM, the ADM stated, they used to have comfort pack on all patients, but they stopped ordering since patient is needing it. ADM stated, all the patients located at the assisted living facility have oxygen concentrators, but the maintenance staff removed them from the rooms. ADM stated, from this year on, they will discuss the medication (Comfort Pack) and DME issues on their meeting what the (survey) team found.   During a review of the HA’s policy and procedure (P&P) titled, “The Plan of Care”, dated April 2013, the “The Plan of Care” indicated:  POLICYA written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days.  PROCEDUE 1.     The Case Manage (or admitting registered nurse) will complete the initialassessment and will initiate the development of the plan of care after consent forms are signed.4.   The plan of care will identify the patient’s needs and services to meet those            needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver’s needs.12. The written plan of care will contain, but not limited to, the following:        I. DME and medical supplies necessary to meet the patient's needs        P. Plan and symptom management interventions13. All appropriate hospice staff will have access to the plan of care.14. Care provided to the patient will be in accordance with the plan of care.     Findings:1a. During a review of Patient 1’s Personal Information Record, the record indicated Patient 1’s Start of Care (SOC) was 10/30/2023, with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time) and Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do). During a review of Patient 1’s “Current Treatment/Medication/DME List,” dated 4/1/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 1’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Pain will remain in comfortable level during care. Pain will be relieved within 30 minutes – 1 hour with interventions. Interventions…Pain management as ordered.”b. During a review of Patient 2’s Personal Information Record, the record indicated Patient 2’s SOC was 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia, dementia (loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult). During a review of Patient 2’s “Current Treatment/Medication/DME List,” dated 11/7/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 2’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Pain will be relieved within 30 minutes – 1 hour with interventions. Interventions…Resolve pain with medications ordered…”c. During a review of Patient 3’s Personal Information Record, the record indicated Patient 3’s SOC was 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip). During a review of Patient 3’s “Current Treatment/Medication/DME List,” dated 10/21/2023, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 3’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Pain will be relieved within 30 minutes – 1 hour with interventions. Will be free of pain daily. Interventions…Resolve pain with medications ordered…”d. During a review of Patient 4’s Personal Information Record, the record indicated Patient 4’s SOC was 3/26/2025, with primary diagnosis of metabolic encephalopathy with Alzheimer’s Disease. During a review of Patient 4’s “Current Treatment/Medication/DME List,” dated 3/26/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 4’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Pain will be relieved after interventions. Interventions… Pain management as ordered…”e. During a review of Patient 5’s Personal Information Record, the record indicated Patient 5’s SOC was 2/12/2025, with primary diagnosis of metabolic encephalopathy with healed traumatic fracture (healed bone break). During a review of Patient 5’s “Current Treatment/Medication/DME List,” dated 2/12/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 5’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Pain will be relieved after nursing intervention/medication. Interventions…Resolve pain with medications ordered…”f. During a review of Patient 6’s Personal Information Record, the record indicated Patient 6’s SOC was 12/6/2024, with primary diagnosis of metabolic encephalopathy with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering [myelin] on nerve fibers in the brain and spinal cord). During a review of Patient 6’s “Current Treatment/Medication/DME List,” dated 12/6/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 6’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Will be free of pain daily. Interventions…Resolve pain with medications…”g. During a review of Patient 7’s Personal Information Record, the record indicated Patient 7’s SOC was 8/15/2024, with primary diagnosis of metabolic encephalopathy, Alzheimer’s Disease, dementia (loss of thinking, remembering and reasoning skill) and chronic back/legs pain (long-term pain to back and legs). During a review of Patient 7’s “Current Treatment/Medication/DME List,” dated 8/15/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 7’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Pain will be relieved within 30 minutes – 1 hour after interventions.”h. During a review of Patient 8’s Personal Information Record, the record indicated Patient 8’s SOC was 6/16/2024, with metabolic encephalopathy and dementia. During a review of Patient 8’s “Current Treatment/Medication/DME List,” dated 6/16/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 8’s “POC/IDG Review,” dated 5/5/2025, the POC for Pain indicated, “Goals: Will be free of s/sx (signs and symptoms) of alteration in comfort. Interventions…Monitor/assess effectiveness of current and new medication/treatment…”i. During a review of Patient 9’s Personal Information Record, the record indicated Patient 9’s SOC was 4/4/2024, with diagnosis of metabolic encephalopathy, type 2 diabetes mellitus (a long-term condition in which the body does not use insulin [a hormone that helps glucose (sugar) from food enter the cells for energy] properly or produce enough insulin).  During a review of Patient 9’s “Current Treatment/Medication/DME List,” dated 4/4/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient.During a review of Patient 9’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: pain will be relieved to < (less than) 3 or stated comfort level of pain by patient after nursing intervention/medication. Pain will be relieved within 30 minutes – 1 hour after interventions. Interventions…Resolve pain with medications ordered…”During a concurrent observation and interview, on 5/15/2025 at 2:39 pm, with Medication Tech 1 (MT 1), MT 1 was observed looking for Patient 1, Patient 2, and Patient 3’s comfort pack medications in the medication cart. MT 1 stated she did not have Patient 1, Patient 2, and Patient 3’s comfort pack medications.During a concurrent observation and interview, on 5/16/25 at 2:24 pm, with the VRN, the VRN was observed looking for Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications in the medication cart. The VRN stated Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications were missing and does not have those medications. During an interview on 5/16/25 at 4:26 pm, with the VRN, the VRN stated she was the one responsible for ensuring all of the patients’ medications, ordered by the physician, are available for administration. The VRN stated she was not checking the patients’ comfort pack medications because the patients were not using it. During an interview on 5/16/25 at 4:26 pm, the VRN stated she was the one responsible in coordinating the care and reviewing the patients’ medication during the Interdisciplinary Group (IDG, a team of healthcare professionals from different disciplines who work collaboratively to provide comprehensive and individualized care for hospice patients and their families) meetings. The VRN stated she discuss in the IDG meetings any concern or issue with the patients’ medications including the efficacy of the treatment, new medication, and any need for change or discontinuation of the medications. The VRN stated she did not discuss and consult the physician during the IDG meetings regarding the patients’ comfort packs medication if needed to change or discontinued.During an interview on 5/17/2025 at 4:15 pm, with the Administrator (ADM), the ADM stated they used to have comfort pack medications on all of the patients, but they stopped ordering since the patients are not needing it. 2. During a review of Patient 2’s “Current Treatment/Medication/DME List,” dated 11/7/2024, the list indicated a physician’s order for, “oxygen 2-5 LPM (liter per minute) via nasal cannula PRN (as needed) for SOB (shortness of breath).During a review of Patient 2’s “POC/IDG Review,” dated 5/12/2025, the POC for Respiratory indicated, “Goals: Pt (Patient) will have optimum level of oxygen…Intervention…Oxygen as ordered vis NC (nasal canula) at 2-5 l/min as needed…”During an observation on 5/15/2025 at 2:01 pm, with the Visiting Registered Nurse (VRN), Patient 2 was observed in her room, lying in bed and was conversant with the VRN. No oxygen machine was observed inside Patient 2’s room. During an interview on 5/16/2025 at 6:13 pm, with the VRN, the VRN stated it was her responsibility to review the patient’s care plan and ensure the interventions were being implemented. The VRN stated it was her responsibility to ensure Patient 2’s oxygen concentrator was available for use as needed by the patient.During a review of the facility’s policy and procedure (P&P) titled, “THE PLAN OF CARE,” revised in April 2013, the P&P indicated, “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care…The plan of care will be based on the initial comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days…PROCEDURE…The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver’s needs…Care provided to the patient will be in accordance with the plan of care.”

Based on observation, interview, and record review, the facility failed to implement the individualized written plan of care (POC, a written document that outlines the specific needs and services provided to a hospice patient and their family/caregiver) on pain management and respiratory care for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). This failure had the potential for the patients’ needs and risks to not be addressed and may lead to increased pain, suffering, emergency hospitalization and may contribute to an avoidable traumatic death. --- Findings: 1a. During a review of Patient 1’s Personal Information Record, the record indicated Patient 1’s Start of Care (SOC) was 10/30/2023, with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time) and Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do). During a review of Patient 1’s “Current Treatment/Medication/DME List,” dated 4/1/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 1’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Pain will remain in comfortable level during care. Pain will be relieved within 30 minutes – 1 hour with interventions. Interventions…Pain management as ordered.”b. During a review of Patient 2’s Personal Information Record, the record indicated Patient 2’s SOC was 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia, dementia (loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult). During a review of Patient 2’s “Current Treatment/Medication/DME List,” dated 11/7/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 2’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Pain will be relieved within 30 minutes – 1 hour with interventions. Interventions…Resolve pain with medications ordered…”c. During a review of Patient 3’s Personal Information Record, the record indicated Patient 3’s SOC was 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip). During a review of Patient 3’s “Current Treatment/Medication/DME List,” dated 10/21/2023, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 3’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Pain will be relieved within 30 minutes – 1 hour with interventions. Will be free of pain daily. Interventions…Resolve pain with medications ordered…”d. During a review of Patient 4’s Personal Information Record, the record indicated Patient 4’s SOC was 3/26/2025, with primary diagnosis of metabolic encephalopathy with Alzheimer’s Disease. During a review of Patient 4’s “Current Treatment/Medication/DME List,” dated 3/26/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 4’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Pain will be relieved after interventions. Interventions… Pain management as ordered…”e. During a review of Patient 5’s Personal Information Record, the record indicated Patient 5’s SOC was 2/12/2025, with primary diagnosis of metabolic encephalopathy with healed traumatic fracture (healed bone break). During a review of Patient 5’s “Current Treatment/Medication/DME List,” dated 2/12/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 5’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Pain will be relieved after nursing intervention/medication. Interventions…Resolve pain with medications ordered…”f. During a review of Patient 6’s Personal Information Record, the record indicated Patient 6’s SOC was 12/6/2024, with primary diagnosis of metabolic encephalopathy with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering [myelin] on nerve fibers in the brain and spinal cord). During a review of Patient 6’s “Current Treatment/Medication/DME List,” dated 12/6/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 6’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Will be free of pain daily. Interventions…Resolve pain with medications…”g. During a review of Patient 7’s Personal Information Record, the record indicated Patient 7’s SOC was 8/15/2024, with primary diagnosis of metabolic encephalopathy, Alzheimer’s Disease, dementia (loss of thinking, remembering and reasoning skill) and chronic back/legs pain (long-term pain to back and legs). During a review of Patient 7’s “Current Treatment/Medication/DME List,” dated 8/15/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 7’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: Pain will be relieved within 30 minutes – 1 hour after interventions.”h. During a review of Patient 8’s Personal Information Record, the record indicated Patient 8’s SOC was 6/16/2024, with metabolic encephalopathy and dementia. During a review of Patient 8’s “Current Treatment/Medication/DME List,” dated 6/16/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. During a review of Patient 8’s “POC/IDG Review,” dated 5/5/2025, the POC for Pain indicated, “Goals: Will be free of s/sx (signs and symptoms) of alteration in comfort. Interventions…Monitor/assess effectiveness of current and new medication/treatment…”i. During a review of Patient 9’s Personal Information Record, the record indicated Patient 9’s SOC was 4/4/2024, with diagnosis of metabolic encephalopathy, type 2 diabetes mellitus (a long-term condition in which the body does not use insulin [a hormone that helps glucose (sugar) from food enter the cells for energy] properly or produce enough insulin).  During a review of Patient 9’s “Current Treatment/Medication/DME List,” dated 4/4/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient.During a review of Patient 9’s “POC/IDG Review,” dated 5/12/2025, the POC for Pain indicated, “Goals: pain will be relieved to < (less than) 3 or stated comfort level of pain by patient after nursing intervention/medication. Pain will be relieved within 30 minutes – 1 hour after interventions. Interventions…Resolve pain with medications ordered…”During a concurrent observation and interview, on 5/15/2025 at 2:39 pm, with Medication Tech 1 (MT 1), MT 1 was observed looking for Patient 1, Patient 2, and Patient 3’s comfort pack medications in the medication cart. MT 1 stated she did not have Patient 1, Patient 2, and Patient 3’s comfort pack medications.During a concurrent observation and interview, on 5/16/25 at 2:24 pm, with the VRN, the VRN was observed looking for Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications in the medication cart. The VRN stated Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications were missing and does not have those medications. During an interview on 5/16/25 at 4:26 pm, with the VRN, the VRN stated she was the one responsible for ensuring all of the patients’ medications, ordered by the physician, are available for administration. The VRN stated she was not checking the patients’ comfort pack medications because the patients were not using it. During an interview on 5/16/25 at 4:26 pm, the VRN stated she was the one responsible in coordinating the care and reviewing the patients’ medication during the Interdisciplinary Group (IDG, a team of healthcare professionals from different disciplines who work collaboratively to provide comprehensive and individualized care for hospice patients and their families) meetings. The VRN stated she discuss in the IDG meetings any concern or issue with the patients’ medications including the efficacy of the treatment, new medication, and any need for change or discontinuation of the medications. The VRN stated she did not discuss and consult the physician during the IDG meetings regarding the patients’ comfort packs medication if needed to change or discontinued.2. During a review of Patient 2’s “Current Treatment/Medication/DME List,” dated 11/7/2024, the list indicated a physician’s order for, “oxygen 2-5 LPM (liter per minute) via nasal cannula PRN (as needed) for SOB (shortness of breath).During a review of Patient 2’s “POC/IDG Review,” dated 5/12/2025, the POC for Respiratory indicated, “Goals: Pt (Patient) will have optimum level of oxygen…Intervention…Oxygen as ordered vis NC (nasal canula) at 2-5 l/min as needed…”During an observation on 5/15/2025 at 2:01 pm, with the Visiting Registered Nurse (VRN), Patient 2 was observed in her room, lying in bed and was conversant with the VRN. No oxygen machine was observed inside Patient 2’s room. During an interview on 5/16/2025 at 6:13 pm, with the VRN, the VRN stated it was her responsibility to review the patient’s care plan and ensure the interventions were being implemented. The VRN stated it was her responsibility to ensure Patient 2’s oxygen concentrator was available for use as needed by the patient.During a review of the facility’s policy and procedure (P&P) titled, “THE PLAN OF CARE,” revised in April 2013, the P&P indicated, “A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care…The plan of care will be based on the initial comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days…PROCEDURE…The plan of care will identify the patient’s needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver’s needs…Care provided to the patient will be in accordance with the plan of care.” During a review of Patient 1 Personal Information Record, the personal Information Record indicated Patient 1 Start of Care (SOC) was 10/30/2023 with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time), Alzheimer’s dementia (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do).  During a review of Patient 2 Personal Information Record, the Personal Information Record indicated Patient 2 SOC  was 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia ( a condition where there’s not enough oxygen or too much carbon dioxide in the body over time), dementia ( loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult).  During a review of Patient 3 Personal Information Record, the Personal Information Record indicated Patient 3 SOC was 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip).  During a review of  Patient 4 Personal Information Record, the Personal Information Record  indicated Patient 4 SOC was 3/26/2025, with primary diagnosis of Metabolic Encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do).  During a review of Patient 5 Personal Information Record, the Personal Information Record indicated Patient 5 SOC was 2/21/2025, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with healed traumatic fracture (healed bone break).  During a review of Patient 6 Personal Information Record, the Personal Information Record indicated Patient 6 SOC was 12/6/2024, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering (myelin) on nerve fibers in the brain and spinal cord).  During a review of Patient 7 Personal Information Record, the Personal Information Record indicated Patient 7 SOC was 8/15/2024 with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes), Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do), dementia  (loss of thinking, remembering, and reasoning skill) and chronic back/legs pain (long-term pain to back and legs).  During a review of Patient 8 Personal Information Record, the Personal Information Record indicated Patient 8 SOC was 6/16/2024, with metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) and dementia (loss of thinking, remembering, and reasoning skill).  During a review of Patient 9 Personal Information Record, the Personal Information Record indicated Patient 9 SOC was 4/4/2024 with diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes), type 2 diabetes mellitus (diabetes mellitus is a long-term condition in which the body does not use insulin (a hormone that helps glucose (sugar) from food enter the cells for energy) properly or produce enough insulin.  During a review of Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9 POC/IDG Review Record, the POC/IDG Review Record dated 3/31/2025, 4/14/2025, 4/28/2025, and 5/12/2025 indicated the following:Pain Goals  -          Pain will remain in comfortable level during care-          Pain will be relieved within 30 minutes – 1 hour with interventionsPain Interventions-          Pain management as ordered-          Resolve pain with medications as ordered.  Teach patient/family/patient caregiver on immediate use, efficacy, and precautions. During a review of Patient 1 and Patient 2, POC/IDG Review Record, the POC/IDG Review Record dated 3/31/2025, 4/14/2025, 4/28/2025, and 5/12/2025 indicated the following:Respiratory Goals-          Patient will have optimum level of oxygen (a colorless, odorless gas vital for life)-          Patient will be free from signs and symptoms of altered respiratory status During a review of the patients’ (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9) physician’s order indicated the following order comfort pack medications, such as morphine (narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain), lorazepam (a benzodiazepine that works in the brain to relieve symptoms of anxiety), and ondansetron (used to prevent nausea and vomiting):1. Morphine Sulfate 0.25 milliliters (ml, a unit of measurement) sublingual (under the tongue) every 4 hours as needed for moderate to severe pain.2. Lorazepam 2 mg per ml, 1 ml sublingual every 4 hours as needed for anxiety and agitation.3. Ondansetron ODT 4 milligrams (mg, a unit of measurement) tablet sublingual every 6 hours as needed for nausea and vomiting. Included in the physician’s order is the durable medical equipment (DME) oxygen concentrator (a device that increases the concentration of oxygen in air, usually from the ambient environment, by removing nitrogen, commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions) for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9. During a concurrent observation and interview on 5/15/2025 at 2:39 PM with Med Tech 1 in the assisted living facility’s medication room, Patient 1, Patient 2, and Patient 3‘s comfort pack medications were verified by the Med Tech 1 that the medications were missing. Med Tech 1 stated she does not have those medications (Morphine, Ativan, and Ondansetron) for the patients. During a concurrent observation and interview on 5/16/2025 at 2:24 PM with the Visiting Registered Nurse (RN) in the assisted living facility’s medication room, the Visiting RN stated Morphine, Ativan, and Ondansetron were missing for Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9. During an interview on 5/16/2025 at 4:26 PM with the Visiting RN, the Visiting RN stated she was the one responsible in ensuring all the patients’ medications ordered by the physician are available for administration. The RN stated she was not checking the patients’ comfort pack medications because the patients were not using it.  The Visiting RN stated she was the one responsible in coordinating the care and reviewing the patients’ medication during the Interdisciplinary Group (IDG) meeting. The Visiting RN stated she should present to the IDG any concern or issue with the patients’ medications including the efficacy of the treatment, new medications, and any need for change or discontinuation of the medications.  The Visiting RN stated she did not discuss and consult the physician during the IDG regarding the patients’ comfort packs medication if needed to change or discontinued. During an interview on 5/16/2025 at 6:13 PM with the Visiting RN, the Visiting RN stated it is her responsibility to ensure the patients’ durable medical equipment (DME, refers to reusable medical devices and equipment, prescribed by a healthcare provider, that are used to aid in the treatment or management of a medical condition), such as the oxygen concentrator, as ordered by the physician, were available for use as needed by the patients. During a review of the hospice agency’s policy and procedure (P&P) titled, “THE PLAN OF CARE,” revised April 2013, the P&P indicated:   POLICYA written individualized patient and family/caregiver plan of care will be established and maintained for each individual to the hospice program.  The care provided to the patient must be in accordance with the plan of care.  The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process.  The plan of care will be based on the on the initial, comprehensive and ongoing comprehensive assessments performed by members of the IDG ….This plan will focus on identified problems, goals, and interventions. PROCEDURE8.  Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments, and analysis of patient response to care against goals and outcomes.  10.  Any change in the patient’s condition must result in a change in the plan of care, prior to implementation of the new service.  12.  The written plan of care will contain, but will not be limited to, the following:         I.  DME and medical supplies necessary to meet patient needs         L.  Individualized interventions to assist with end-of-life care         Q.  Drugs and treatments (including allergies)  14.  Care provided to the patient will be in accordance with the plan of care.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the condition of participation (CoP-a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Quality Assessment and Performance Improvement were met as follows: --- 1. The facility failed to provide documented evidence that the facility’s Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) used quality indicators (specific, quantifiable metrics that can be tracked over time) that shows measurable improvement related to palliative outcomes and hospice services received by nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).This failure resulted in the facility’s QAPI program to not have a system that effectively assess and identify needs for improvement in providing quality and safe care that may have contributed to the lack of patient care coordination for assessment of the patients’ needs when,  Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, were not available for the patients to use when needed. In addition, this failure has a potential to result in an inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death to the patients. (Refer to L561)2. The facility failed to demonstrate a process and provide documented evidence the facility’s Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) program was measuring, analyzing, and tracking quality indicators (are specific, quantifiable metrics that can be tracked over time) that enabled the facility to assess processes of care, hospice services (a specialized form of end-of-life care that provides comfort, support, and medical assistance to terminally ill patients and their families that focuses on improving the quality of life and easing suffering during the final stages of life), and operations for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).This failure resulted in the facility’s QAPI program to not have a system that effectively assess and identify needs for improvement in providing quality and safe care that may have contributed to the lack of patient care coordination for assessment of the patients’ needs when,  Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, were not available for the patients to use when needed. In addition, this failure has a potential to result in an inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death to the patients. (Refer to L562)3. The facility failed to provide documented evidence that the facility’s Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) program used data collection for monitoring effectiveness and safety of services and quality of care, and identify opportunities and needs for improvement on the care provided to nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).This failure resulted in the facility’s QAPI program to not have a system that effectively assess and identify needs for improvement in providing quality and safe care that may have contributed to the lack of patient care coordination for assessment of the patients’ needs when,  Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, were not available for the patients to use when needed. In addition, this failure has a potential to result in an inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death to the patients. (Refer to L564)4. The facility failed to provide documented evidence that the facility’s Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) improvement project activities were focus on high risk, high volume, or problem-prone areas for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).This failure resulted in the facility’s QAPI program to not have a system that effectively assess and identify needs for improvement in providing quality and safe care that may have contributed to the lack of patient care coordination for assessment of the patients’ needs when,  Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, were not available for the patients to use when needed. In addition, this failure has a potential to result in an inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death to the patients. (Refer to L566)5. The facility failed to provide documented evidence that the facility’s Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) improvement project activities were based on the needs of the hospice patients and staff, and performance of the hospice services and operations for nine of nine sampled  patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). This failure resulted in the facility’s QAPI program to not have a system that effectively assess and identify needs for improvement in providing quality and safe care that may have contributed to the lack of patient care coordination for assessment of the patients’ needs when,  Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, were not available for the patients to use when needed. In addition, this failure has a potential to result in an inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death to the patients. (Refer to L572)The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (relating to rules or laws which have been formally written down) mandated compliance with the Federal regulations for Quality Assessment & Performance Improvement to ensure provision of the highest quality of care for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9 who were assessed to receive hospice care services.

Based on observation, interview, and record review, the facility failed to provide documented evidence that the facility’s Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) used quality indicators (specific, quantifiable metrics that can be tracked over time) that shows measurable improvement related to palliative outcomes and hospice services received by nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).This failure resulted in the facility’s QAPI program to not have a system that effectively assess and identify needs for improvement in providing quality and safe care that may have contributed to the lack of patient care coordination for assessment of the patients’ needs when,  Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, were not available for the patients to use when needed. In addition, this failure has a potential to result in an inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death to the patients. --- Findings:a. During a review of Patient 1’s Personal Information Record, the record indicated Patient 1’s Start of Care (SOC) was 10/30/2023, with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time) and Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do). During a review of Patient 1’s “Current Treatment/Medication/DME List,” dated 4/1/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. b. During a review of Patient 2’s Personal Information Record, the record indicated Patient 2’s SOC was 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia, dementia (loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult). During a review of Patient 2’s “Current Treatment/Medication/DME List,” dated 11/7/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient and oxygen 2 to 5 liter per minute (lpm) via nasal cannula as needed for shortness of breath. c. During a review of Patient 3’s Personal Information Record, the record indicated Patient 3’s SOC was 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip). During a review of Patient 3’s “Current Treatment/Medication/DME List,” dated 10/21/2023, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. d. During a review of Patient 4’s Personal Information Record, the record indicated Patient 4’s SOC was 3/26/2025, with primary diagnosis of metabolic encephalopathy with Alzheimer’s Disease. During a review of Patient 4’s “Current Treatment/Medication/DME List,” dated 3/26/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. e. During a review of Patient 5’s Personal Information Record, the record indicated Patient 5’s SOC was 2/12/2025, with primary diagnosis of metabolic encephalopathy with healed traumatic fracture (healed bone break). During a review of Patient 5’s “Current Treatment/Medication/DME List,” dated 2/12/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. f. During a review of Patient 6’s Personal Information Record, the record indicated Patient 6’s SOC was 12/6/2024, with primary diagnosis of metabolic encephalopathy with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering [myelin] on nerve fibers in the brain and spinal cord). During a review of Patient 6’s “Current Treatment/Medication/DME List,” dated 12/6/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. g. During a review of Patient 7’s Personal Information Record, the record indicated Patient 7’s SOC was 8/15/2024, with primary diagnosis of metabolic encephalopathy, Alzheimer’s Disease, dementia (loss of thinking, remembering and reasoning skill) and chronic back/legs pain (long-term pain to back and legs). During a review of Patient 7’s “Current Treatment/Medication/DME List,” dated 8/15/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. h. During a review of Patient 8’s Personal Information Record, the record indicated Patient 8’s SOC was 6/16/2024, with metabolic encephalopathy and dementia. During a review of Patient 8’s “Current Treatment/Medication/DME List,” dated 6/16/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. i. During a review of Patient 9’s Personal Information Record, the record indicated Patient 9’s SOC was 4/4/2024, with diagnosis of metabolic encephalopathy, type 2 diabetes mellitus (a long-term condition in which the body does not use insulin [a hormone that helps glucose (sugar) from food enter the cells for energy] properly or produce enough insulin).  During a review of Patient 9’s “Current Treatment/Medication/DME List,” dated 4/4/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient.During an observation on 5/15/2025 at 2:01 pm, with the Visiting Registered Nurse (VRN), Patient 2 was observed in her room, lying in bed and was conversant with the VRN. No oxygen machine was observed inside Patient 2’s room. During a concurrent observation and interview, on 5/15/2025 at 2:39 pm, with Medication Tech 1 (MT 1), MT 1 was observed looking for Patient 1, Patient 2, and Patient 3’s comfort pack medications in the medication cart. MT 1 stated she did not have Patient 1, Patient 2, and Patient 3’s comfort pack medications.During a concurrent observation and interview, on 5/16/25 at 2:24 pm, with the VRN, the VRN was observed looking for Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications in the medication cart. The VRN stated Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications were missing and does not have those medications.During an interview on 5/17/2025 at 3:35 PM, with the Administrator (ADM), the ADM stated she was a member and leader of the QAPI. The ADM stated the QAPI quarterly report was being submitted and reported during the Interdisciplinary Group (IDG, a team of healthcare professionals from different disciplines who work collaboratively to provide comprehensive and individualized care for hospice patients and their families) meeting. The ADM stated the QAPI committee meeting was only done once a year, at the end of year (annual) with Governing Body (GB, is responsible for the overall management of the hospice, including its legal, financial, and operational aspects. The GB ensures the facility adheres to regulations, provides high quality care, and continuously improves its services) meeting. During a concurrent interview and record review, on 5/17/2025 at 3:38 PM, with the ADM, the facility’s “QAPI agenda and minutes” for 12/2024 was reviewed. The ADM stated the purpose of QAPI was to review the care areas for the facility to focus on. The ADM stated she was the one who decides what projects the QAPI committee would need to work on. The ADM stated the QAPI project was based on what the previous QAPI had been doing since 2015.  The ADM stated the committee was aware of all scheduled QAPI projects and agreed to proceed as scheduled. During an interview on 5/17/2025 at 3:38 PM, the ADM stated the facility’s QAPI project were scheduled quarterly. The ADM stated on the first (1st) quarter (January to March) the QAPI project was focus on family satisfaction, the second (2nd) quarter (April to June) the QAPI project was infection control, the third (3rd) quarter (July to September) the QAPI project was focus on their general inpatient care, and the fourth (4th) quarter (October to December) the QAPI project was on the documentation compliance for continuous care patients. The ADM stated she did not use any other data and/or quality measure (tools used to quantify the performance of healthcare providers and facilities to ensure patients receive high-quality care) to determine what project the QAPI committee will work on.During an interview on 5/17/2025 at 3:38 PM, the ADM stated the facility’s QAPI project for the 2nd quarter of 2024 was on fall because there was a fall incident. The ADM stated the QAPI goal for the fall project was to establish a better reporting system and communication of fall incident. The ADM was not able to provide results of the QAPI project for fall for the 2nd quarter of 2024. During a concurrent interview and record review, on 5/17/2025 at 3:39 PM, with the ADM, the “QAPI agenda and minutes” for 12/2024 was reviewed. The QAPI minutes had no documentation of QAPI report and analysis of the scheduled QAPI project from January 2024 through May 2025. The ADM stated the QAPI’s schedule every 3rd quarter of the year was focused on the hospice care of general inpatient care. The ADM stated the facility does not have any general inpatient cases, and they never had one. The ADM stated because the general inpatient care project was included in the QAPI program before and it became habitual for them that the QAPI committee just continue doing it, even if it had zero result because of no inpatient cases. The ADM stated she does not have any data gathering or tracking process to obtain information and/or identify any issue or improvement needed on the hospice services being provided to the patients.During an interview on 5/18/2025 at 11:08 AM, with the ADM, the ADM stated the facility’s QAPI report does not have analysis of the information gathered, no recommendation or action plan based on the information gathered.During a review of the facility’s policy and procedure (P&P) titled, “Improving Organizational Performance/Quality Assessment and Performance Improvement,” dated April 2012, the P&P indicated, “The hospice shall have an organized system for assessing and improving the quality of care and services. The QAPI shall be designed to improve performance on a systematic and continuous basis. The system shall consist of planned and measurable mechanisms for data collection, analysis and process for the improvement within the specific time frames. The hospice shall implement performance improvement processes that routinely assess and improve all services provided and by written agreement. All personnel will be active participants in hospice quality assessment performance improvement (QAPI) activities. Set expectations for performance improvement and manage processes to improve organization. Adopt a scientific, problem-solving data driven approach to quality assessment and performance improvement (QAPI). The scientific, problem-solving approach will include planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume or problem prone areas. These may include risk management, such as adverse pain events and medication management, utilization management, quality control, patient safety program, palliative outcomes tracking such as pain control. Provide hospice personnel training in effective approaches and methods of assessment and improvement.”

Based on observation, interview, and record review, the facility failed to demonstrate a process and provide documented evidence the facility’s Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) program was measuring, analyzing, and tracking quality indicators (are specific, quantifiable metrics that can be tracked over time) that enabled the facility to assess processes of care, hospice services (a specialized form of end-of-life care that provides comfort, support, and medical assistance to terminally ill patients and their families that focuses on improving the quality of life and easing suffering during the final stages of life), and operations for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).This failure resulted in the facility’s QAPI program to not have a system that effectively assess and identify needs for improvement in providing quality and safe care that may have contributed to the lack of patient care coordination for assessment of the patients’ needs when,  Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, were not available for the patients to use when needed. In addition, this failure has a potential to result in an inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death to the patients.  On 5/18/2025, at 5:14 PM., the Department called an Immediate Jeopardy (IJ, a situation in which the agency’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the Administrator (ADM) for failing to demonstrate a process and provide documented evidence the facility was measuring, analyzing, and tracking quality indicators  that enabled the facility to assess processes of care, hospice services, and operations for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).On 6/6/2025 at 1:00 p.m., after confirming the facility's implementation of the immediate corrective actions from the accepted IJ removal plan, the Department  removed the Immediate Jeopardy while onsite, in the presence of the Office Manager. --- During a review of Patient 1 Personal Information Record, the personal Information Record indicated Patient 1 Start of Care (SOC) was 10/30/2023 with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time), Alzheimer’s dementia (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do). During a review of Patient 2 Personal Information Record, the Personal Information Record indicated Patient 2 SOC  was 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia ( a condition where there’s not enough oxygen or too much carbon dioxide in the body over time), dementia ( loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult). During a review of Patient 3 Personal Information Record, the Personal Information Record indicated Patient 3 SOC was 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip). During a review of  Patient 4 Personal Information Record, the Personal Information Record  indicated Patient 4 SOC was 3/26/2025, with primary diagnosis of Metabolic Encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do). During a review of Patient 5 Personal Information Record, the Personal Information Record indicated Patient 5 SOC was 2/21/2025, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with healed traumatic fracture (healed bone break). During a review of Patient 6 Personal Information Record, the Personal Information Record indicated Patient 6 SOC was 12/6/2024, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering (myelin) on nerve fibers in the brain and spinal cord). During a review of Patient 7 Personal Information Record, the Personal Information Record indicated Patient 7 SOC was 8/15/2024 with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes), Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do), dementia  (loss of thinking, remembering and reasoning skill) and chronic back/legs pain (long-term pain to back and legs). During a review of Patient 8 Personal Information Record, the Personal Information Record indicated Patient 8 SOC was 6/16/2024, with metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) and dementia. During a review of Patient 9 Personal Information Record, the Personal Information Record indicated Patient 9 SOC was 4/4/2024 with diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes), type 2 diabetes mellitus (diabetes mellitus is a long-term condition in which the body does not use insulin (a hormone that helps glucose (sugar) from food enter the cells for energy) properly or produce enough insulin.  During an interview on 5/17/2025 at 3:35 PM, the Administrator (ADM) stated she was a member and leader of the Quality Assurance and Performance Improvement (QAPI, a structured approach that hospice organizations use to continuously monitor, assess, and improve the quality of patient care and services) committee. The ADM stated the QAPI quarterly report was being submitted and reported during the Interdisciplinary Group (IDG, a team of healthcare professionals from different disciplines who work collaboratively to provide comprehensive and individualized care for hospice patients and their families) meeting. The ADM stated the QAPI committee meeting was only done once a year, at the end of year (annual) with Governing Body (GB, is responsible for the overall management of the hospice, including its legal, financial, and operational aspects. The GB ensures the hospice adheres to regulations, provides high quality care, and continuously improves its services) meeting. During a concurrent interview and record review on 5/17/2025 at 3:38 PM, with the ADM, the HA “QAPI agenda and minutes” for 12/2024 was reviewed. The ADM stated the purpose of QAPI was to review the areas for the HA to focus. The ADM stated she was the one who decides what the QAPI would need to work. The ADM stated the QAPI project was based on what the previous QAPI had been doing since 2015.  The ADM stated the committee was aware of all scheduled programs and agreed to proceed as scheduled. The ADM stated the HA’s QAPI has a quarterly schedule on what they were working on: First (1st) quarter – family satisfaction, second (2nd) quarter – infection control, third (3rd) quarter – general inpatient care (GIP), and fourth (4th) quarter – documentation for continuous care (compliance/documentation). The ADM stated she does not use any other data and/or quality measure (tools used to quantify the performance of healthcare providers and facilities to ensure patients receive high-quality care) to determine what QAPI committee will work on.During a concurrent interview and record review on 5/17/2025 at 3:39 PM, with the ADM, “QAPI agenda and minutes” for 12/2024 for Patient Satisfaction, Infection Control, General Inpatient, and Documentation for Continuous Care was reviewed. The QAPI minutes indicated there was no documented evidence of documentation of QAPI report and analysis of the report for 2024 through May 2025. The ADM stated the QAPI’s schedule was every 3rd quarter of the year and was focused on the care of general inpatient care.  The ADM stated they do not have any general inpatient cases, and they never had one. The hospice agency never provided services for general inpatient care. The ADM stated because the general inpatient care was included in the QAPI program before they just continue doing it even if it shows zero result because of no inpatient cases. The hospice agency does not have any data compared to the National Benchmark quality indicators. The QAPI committee continued this as scheduled and stated no one made changes. The ADM stated she knew there was no issue in the HA. The ADM stated she does not have any data gathering or tracking process to obtain information for any issue or need in improvement of the HA’s service to the patient.During an interview on 5/17/2025 at 3:55 PM, the ADM stated she has Master of Social Work (MSW – a graduate level degree that provides advanced training and education in the field of social work) by profession. The ADM stated she oversees HA’s operations, and the Director of Patient Care Services (DPCS) oversees clinician license staff and patient care. The ADM stated the DPCS was currently on vacation and the Designee can be interviewed.During an interview on 5/17/2025 at 4:57 PM, with the Director of Patient Care services (DPCS) Designee, the Designee stated she has experience to be the Designee because she was currently a DPCS of another HA. The Designee stated she only covers the HA as designee if the DPCS was not available. The Designee stated the HA’s DPCS was currently on vacation, and she was covering. The Designee stated her responsibility to the HA was to focus on patient care and management of nursing care and what needs to be done for the patients. The Designee stated the HA should have a process on gathering data to base the quality measure and patient safety that would provide information on what needs to work or improve on. The Designee stated she did not receive a hand-off from the DPCS. The Designee stated she should have been given a report or handoff from the DPCS before leaving on vacation, to know what she was dealing with and what she needs to follow up. The Designee stated she needs to know the patient’s condition and what she needed to while covering for DPCS.During an interview on 5/18/2025 at 11:08 AM, the ADM stated the QAPI report does not have analysis of the information gathered, no recommendation or action plan based on the information gathered. During a review of the HA’s policy and procedure (P&P) titled, “Improving Organizational Performance/Quality Assessment and Performance Improvement,” dated April 2012, the P&P indicated, “The hospice shall have an organized system for assessing and improving the quality of care and services. The QAPI shall be designed to improve performance on a systematic and continuous basis. The system shall consist of planned and measurable mechanisms for data collection, analysis and process for the improvement within the specific time frames. The hospice shall implement performance improvement processes that routinely assess and improve all services provided and by written agreement. All personnel will be active participants in hospice quality assessment performance improvement (QAPI) activities. Set expectations for performance improvement and manage processes to improve organization. Adopt a scientific, problem-solving data driven approach to quality assessment and performance improvement (QAPI). The scientific, problem-solving approach will include planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume or problem prone areas. These may include risk management, such as adverse pain events and medication management, utilization management, quality control, patient safety program, palliative outcomes tracking such as pain control. Provide hospice personnel training in effective approaches and methods of assessment and improvement.” Findings:During a review of Patient 1’s Personal Information Record, the record indicated Patient 1’s Start of Care (SOC) was 10/30/2023, with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time) and Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do). During a review of Patient 2’s Personal Information Record, the record indicated Patient 2’s SOC was 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia, dementia (loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult). During a review of Patient 3’s Personal Information Record, the record indicated Patient 3’s SOC was 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip). During a review of Patient 4’s Personal Information Record, the record indicated Patient 4’s SOC was 3/26/2025, with primary diagnosis of metabolic encephalopathy with Alzheimer’s Disease. During a review of Patient 5’s Personal Information Record, the record indicated Patient 5’s SOC was 2/12/2025, with primary diagnosis of metabolic encephalopathy with healed traumatic fracture (healed bone break). During a review of Patient 6’s Personal Information Record, the record indicated Patient 6’s SOC was 12/6/2024, with primary diagnosis of metabolic encephalopathy with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering [myelin] on nerve fibers in the brain and spinal cord). During a review of Patient 7’s Personal Information Record, the record indicated Patient 7’s SOC was 8/15/2024, with primary diagnosis of metabolic encephalopathy, Alzheimer’s Disease, dementia  (loss of thinking, remembering and reasoning skill) and chronic back/legs pain (long-term pain to back and legs). During a review of Patient 8’s Personal Information Record, the record indicated Patient 8’s SOC was 6/16/2024, with metabolic encephalopathy and dementia. During a review of Patient 9’s Personal Information Record, the record indicated Patient 9’s SOC was 4/4/2024, with diagnosis of metabolic encephalopathy, type 2 diabetes mellitus (a long-term condition in which the body does not use insulin [a hormone that helps glucose (sugar) from food enter the cells for energy] properly or produce enough insulin).  During an interview on 5/17/2025 at 3:35 PM, with the Administrator (ADM), the ADM stated she was a member and leader of the QAPI. The ADM stated the QAPI quarterly report was being submitted and reported during the Interdisciplinary Group (IDG, a team of healthcare professionals from different disciplines who work collaboratively to provide comprehensive and individualized care for hospice patients and their families) meeting. The ADM stated the QAPI committee meeting was only done once a year, at the end of year (annual) with Governing Body (GB, is responsible for the overall management of the hospice, including its legal, financial, and operational aspects. The GB ensures the facility adheres to regulations, provides high quality care, and continuously improves its services) meeting. During a concurrent interview and record review, on 5/17/2025 at 3:38 PM, with the ADM, the facility’s “QAPI agenda and minutes” for 12/2024 was reviewed. The ADM stated the purpose of QAPI was to review the care areas for the facility to focus on. The ADM stated she was the one who decides what projects the QAPI committee would need to work on. The ADM stated the QAPI project was based on what the previous QAPI had been doing since 2015.  The ADM stated the committee was aware of all scheduled QAPI projects and agreed to proceed as scheduled. During an interview on 5/17/2025 at 3:38 PM, the ADM stated the facility’s QAPI project were scheduled quarterly. The ADM stated on the first (1st) quarter (January to March) the QAPI project was focus on family satisfaction, the second (2nd) quarter (April to June) the QAPI project was infection control, the third (3rd) quarter (July to September) the QAPI project was focus on their general inpatient care, and the fourth (4th) quarter (October to December) the QAPI project was on the documentation compliance for continuous care patients. The ADM stated she did not use any other data and/or quality measure (tools used to quantify the performance of healthcare providers and facilities to ensure patients receive high-quality care) to determine what project the QAPI committee will work on.During a concurrent interview and record review, on 5/17/2025 at 3:39 PM, with the ADM, the “QAPI agenda and minutes” for 12/2024 was reviewed. The QAPI minutes had no documentation of QAPI report and analysis of the scheduled QAPI project from January 2024 through May 2025. The ADM stated the QAPI’s schedule every 3rd quarter of the year was focused on the hospice care of general inpatient care. The ADM stated the facility does not have any general inpatient cases, and they never had one. The ADM stated because the general inpatient care project was included in the QAPI program before and it became habitual for them that the QAPI committee just continue doing it, even if it had zero result because of no inpatient cases. The ADM stated she does not have any data gathering or tracking process to obtain information and/or identify any issue or improvement needed on the hospice services being provided to the patients.During a review of the facility’s policy and procedure (P&P) titled, “Improving Organizational Performance/Quality Assessment and Performance Improvement,” dated April 2012, the P&P indicated, “The hospice shall have an organized system for assessing and improving the quality of care and services. The QAPI shall be designed to improve performance on a systematic and continuous basis. The system shall consist of planned and measurable mechanisms for data collection, analysis and process for the improvement within the specific time frames. The hospice shall implement performance improvement processes that routinely assess and improve all services provided and by written agreement. All personnel will be active participants in hospice quality assessment performance improvement (QAPI) activities. Set expectations for performance improvement and manage processes to improve organization. Adopt a scientific, problem-solving data driven approach to quality assessment and performance improvement (QAPI). The scientific, problem-solving approach will include planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume or problem prone areas. These may include risk management, such as adverse pain events and medication management, utilization management, quality control, patient safety program, palliative outcomes tracking such as pain control. Provide hospice personnel training in effective approaches and methods of assessment and improvement.”

Based on observation, interview, and record review, the facility failed to provide documented evidence that the facility’s Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) program used data collection for monitoring effectiveness and safety of services and quality of care, and identify opportunities and needs for improvement on the care provided to nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).This failure resulted in the facility’s QAPI program to not have a system that effectively assess and identify needs for improvement in providing quality and safe care that may have contributed to the lack of patient care coordination for assessment of the patients’ needs when,  Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, were not available for the patients to use when needed. In addition, this failure has a potential to result in an inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death to the patients. --- Findings: a. During a review of Patient 1’s Personal Information Record, the record indicated Patient 1’s Start of Care (SOC) was 10/30/2023, with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time) and Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do). During a review of Patient 1’s “Current Treatment/Medication/DME List,” dated 4/1/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. b. During a review of Patient 2’s Personal Information Record, the record indicated Patient 2’s SOC was 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia, dementia (loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult). During a review of Patient 2’s “Current Treatment/Medication/DME List,” dated 11/7/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient and oxygen 2 to 5 liter per minute (lpm) via nasal cannula as needed for shortness of breath. c. During a review of Patient 3’s Personal Information Record, the record indicated Patient 3’s SOC was 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip). During a review of Patient 3’s “Current Treatment/Medication/DME List,” dated 10/21/2023, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. d. During a review of Patient 4’s Personal Information Record, the record indicated Patient 4’s SOC was 3/26/2025, with primary diagnosis of metabolic encephalopathy with Alzheimer’s Disease. During a review of Patient 4’s “Current Treatment/Medication/DME List,” dated 3/26/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. e. During a review of Patient 5’s Personal Information Record, the record indicated Patient 5’s SOC was 2/12/2025, with primary diagnosis of metabolic encephalopathy with healed traumatic fracture (healed bone break). During a review of Patient 5’s “Current Treatment/Medication/DME List,” dated 2/12/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. f. During a review of Patient 6’s Personal Information Record, the record indicated Patient 6’s SOC was 12/6/2024, with primary diagnosis of metabolic encephalopathy with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering [myelin] on nerve fibers in the brain and spinal cord). During a review of Patient 6’s “Current Treatment/Medication/DME List,” dated 12/6/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. g. During a review of Patient 7’s Personal Information Record, the record indicated Patient 7’s SOC was 8/15/2024, with primary diagnosis of metabolic encephalopathy, Alzheimer’s Disease, dementia (loss of thinking, remembering and reasoning skill) and chronic back/legs pain (long-term pain to back and legs). During a review of Patient 7’s “Current Treatment/Medication/DME List,” dated 8/15/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. h. During a review of Patient 8’s Personal Information Record, the record indicated Patient 8’s SOC was 6/16/2024, with metabolic encephalopathy and dementia. During a review of Patient 8’s “Current Treatment/Medication/DME List,” dated 6/16/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. i. During a review of Patient 9’s Personal Information Record, the record indicated Patient 9’s SOC was 4/4/2024, with diagnosis of metabolic encephalopathy, type 2 diabetes mellitus (a long-term condition in which the body does not use insulin [a hormone that helps glucose (sugar) from food enter the cells for energy] properly or produce enough insulin).  During a review of Patient 9’s “Current Treatment/Medication/DME List,” dated 4/4/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient.During an observation on 5/15/2025 at 2:01 pm, with the Visiting Registered Nurse (VRN), Patient 2 was observed in her room, lying in bed and was conversant with the VRN. No oxygen machine was observed inside Patient 2’s room. During a concurrent observation and interview, on 5/15/2025 at 2:39 pm, with Medication Tech 1 (MT 1), MT 1 was observed looking for Patient 1, Patient 2, and Patient 3’s comfort pack medications in the medication cart. MT 1 stated she did not have Patient 1, Patient 2, and Patient 3’s comfort pack medications.During a concurrent observation and interview, on 5/16/25 at 2:24 pm, with the VRN, the VRN was observed looking for Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications in the medication cart. The VRN stated Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications were missing and does not have those medications.During an interview on 5/17/2025 at 3:35 PM, with the Administrator (ADM), the ADM stated she was a member and leader of the QAPI. The ADM stated the QAPI quarterly report was being submitted and reported during the Interdisciplinary Group (IDG, a team of healthcare professionals from different disciplines who work collaboratively to provide comprehensive and individualized care for hospice patients and their families) meeting. The ADM stated the QAPI committee meeting was only done once a year, at the end of year (annual) with Governing Body (GB, is responsible for the overall management of the hospice, including its legal, financial, and operational aspects. The GB ensures the facility adheres to regulations, provides high quality care, and continuously improves its services) meeting. During a concurrent interview and record review, on 5/17/2025 at 3:38 PM, with the ADM, the facility’s “QAPI agenda and minutes” for 12/2024 was reviewed. The ADM stated the purpose of QAPI was to review the care areas for the facility to focus on. The ADM stated she was the one who decides what projects the QAPI committee would need to work on. The ADM stated the QAPI project was based on what the previous QAPI had been doing since 2015.  The ADM stated the committee was aware of all scheduled QAPI projects and agreed to proceed as scheduled. During an interview on 5/17/2025 at 3:38 PM, the ADM stated the facility’s QAPI project were scheduled quarterly. The ADM stated on the first (1st) quarter (January to March) the QAPI project was focus on family satisfaction, the second (2nd) quarter (April to June) the QAPI project was infection control, the third (3rd) quarter (July to September) the QAPI project was focus on their general inpatient care, and the fourth (4th) quarter (October to December) the QAPI project was on the documentation compliance for continuous care patients. The ADM stated she did not use any other data and/or quality measure (tools used to quantify the performance of healthcare providers and facilities to ensure patients receive high-quality care) to determine what project the QAPI committee will work on.During a concurrent interview and record review, on 5/17/2025 at 3:39 PM, with the ADM, the “QAPI agenda and minutes” for 12/2024 was reviewed. The QAPI minutes had no documentation of QAPI report and analysis of the scheduled QAPI project from January 2024 through May 2025. The ADM stated the QAPI’s schedule every 3rd quarter of the year was focused on the hospice care of general inpatient care. The ADM stated the facility does not have any general inpatient cases, and they never had one. The ADM stated because the general inpatient care project was included in the QAPI program before and it became habitual for them that the QAPI committee just continue doing it, even if it had zero result because of no inpatient cases. During an interview on 5/17/2025 at 3:39 PM, The ADM stated she does not have any data gathering or tracking process to obtain information and/or identify any issue or improvement needed on the hospice services being provided to the patients.During an interview on 5/18/2025 at 11:08 AM, the ADM stated the QAPI report does not have analysis of the information gathered, no recommendation or action plan based on the information gathered.During a review of the facility’s policy and procedure (P&P) titled, “Improving Organizational Performance/Quality Assessment and Performance Improvement,” dated April 2012, the P&P indicated, “The hospice shall have an organized system for assessing and improving the quality of care and services. The QAPI shall be designed to improve performance on a systematic and continuous basis. The system shall consist of planned and measurable mechanisms for data collection, analysis and process for the improvement within the specific time frames. The hospice shall implement performance improvement processes that routinely assess and improve all services provided and by written agreement. All personnel will be active participants in hospice quality assessment performance improvement (QAPI) activities. Set expectations for performance improvement and manage processes to improve organization. Adopt a scientific, problem-solving data driven approach to quality assessment and performance improvement (QAPI). The scientific, problem-solving approach will include planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume or problem prone areas. These may include risk management, such as adverse pain events and medication management, utilization management, quality control, patient safety program, palliative outcomes tracking such as pain control. Provide hospice personnel training in effective approaches and methods of assessment and improvement.”

Based on observation, interview, and record review, the facility failed to provide documented evidence that the facility’s Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) improvement project activities were focus on high risk, high volume, or problem-prone areas for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).This failure resulted in the facility’s QAPI program to not have a system that effectively assess and identify needs for improvement in providing quality and safe care that may have contributed to the lack of patient care coordination for assessment of the patients’ needs when,  Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, were not available for the patients to use when needed. In addition, this failure has a potential to result in an inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death to the patients. --- Findings:a. During a review of Patient 1’s Personal Information Record, the record indicated Patient 1’s Start of Care (SOC) was 10/30/2023, with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time) and Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do). During a review of Patient 1’s “Current Treatment/Medication/DME List,” dated 4/1/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. b. During a review of Patient 2’s Personal Information Record, the record indicated Patient 2’s SOC was 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia, dementia (loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult). During a review of Patient 2’s “Current Treatment/Medication/DME List,” dated 11/7/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient and oxygen 2 to 5 liter per minute (lpm) via nasal cannula as needed for shortness of breath. c. During a review of Patient 3’s Personal Information Record, the record indicated Patient 3’s SOC was 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip). During a review of Patient 3’s “Current Treatment/Medication/DME List,” dated 10/21/2023, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. d. During a review of Patient 4’s Personal Information Record, the record indicated Patient 4’s SOC was 3/26/2025, with primary diagnosis of metabolic encephalopathy with Alzheimer’s Disease. During a review of Patient 4’s “Current Treatment/Medication/DME List,” dated 3/26/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. e. During a review of Patient 5’s Personal Information Record, the record indicated Patient 5’s SOC was 2/12/2025, with primary diagnosis of metabolic encephalopathy with healed traumatic fracture (healed bone break). During a review of Patient 5’s “Current Treatment/Medication/DME List,” dated 2/12/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. f. During a review of Patient 6’s Personal Information Record, the record indicated Patient 6’s SOC was 12/6/2024, with primary diagnosis of metabolic encephalopathy with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering [myelin] on nerve fibers in the brain and spinal cord). During a review of Patient 6’s “Current Treatment/Medication/DME List,” dated 12/6/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. g. During a review of Patient 7’s Personal Information Record, the record indicated Patient 7’s SOC was 8/15/2024, with primary diagnosis of metabolic encephalopathy, Alzheimer’s Disease, dementia (loss of thinking, remembering and reasoning skill) and chronic back/legs pain (long-term pain to back and legs). During a review of Patient 7’s “Current Treatment/Medication/DME List,” dated 8/15/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. h. During a review of Patient 8’s Personal Information Record, the record indicated Patient 8’s SOC was 6/16/2024, with metabolic encephalopathy and dementia. During a review of Patient 8’s “Current Treatment/Medication/DME List,” dated 6/16/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. i. During a review of Patient 9’s Personal Information Record, the record indicated Patient 9’s SOC was 4/4/2024, with diagnosis of metabolic encephalopathy, type 2 diabetes mellitus (a long-term condition in which the body does not use insulin [a hormone that helps glucose (sugar) from food enter the cells for energy] properly or produce enough insulin).  During a review of Patient 9’s “Current Treatment/Medication/DME List,” dated 4/4/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient.During an observation on 5/15/2025 at 2:01 pm, with the Visiting Registered Nurse (VRN), Patient 2 was observed in her room, lying in bed and was conversant with the VRN. No oxygen machine was observed inside Patient 2’s room. During a concurrent observation and interview, on 5/15/2025 at 2:39 pm, with Medication Tech 1 (MT 1), MT 1 was observed looking for Patient 1, Patient 2, and Patient 3’s comfort pack medications in the medication cart. MT 1 stated she did not have Patient 1, Patient 2, and Patient 3’s comfort pack medications.During a concurrent observation and interview, on 5/16/25 at 2:24 pm, with the VRN, the VRN was observed looking for Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications in the medication cart. The VRN stated Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications were missing and does not have those medications.During an interview on 5/17/2025 at 3:35 PM, with the Administrator (ADM), the ADM stated she was a member and leader of the QAPI. The ADM stated the QAPI quarterly report was being submitted and reported during the Interdisciplinary Group (IDG, a team of healthcare professionals from different disciplines who work collaboratively to provide comprehensive and individualized care for hospice patients and their families) meeting. The ADM stated the QAPI committee meeting was only done once a year, at the end of year (annual) with Governing Body (GB, is responsible for the overall management of the hospice, including its legal, financial, and operational aspects. The GB ensures the facility adheres to regulations, provides high quality care, and continuously improves its services) meeting. During a concurrent interview and record review, on 5/17/2025 at 3:38 PM, with the ADM, the facility’s “QAPI agenda and minutes” for 12/2024 was reviewed. The ADM stated the purpose of QAPI was to review the care areas for the facility to focus on. The ADM stated she was the one who decides what projects the QAPI committee would need to work on. The ADM stated the QAPI project was based on what the previous QAPI had been doing since 2015.  The ADM stated the committee was aware of all scheduled QAPI projects and agreed to proceed as scheduled. During an interview on 5/17/2025 at 3:38 PM, the ADM stated the facility’s QAPI project were scheduled quarterly. The ADM stated on the first (1st) quarter (January to March) the QAPI project was focus on family satisfaction, the second (2nd) quarter (April to June) the QAPI project was infection control, the third (3rd) quarter (July to September) the QAPI project was focus on their general inpatient care, and the fourth (4th) quarter (October to December) the QAPI project was on the documentation compliance for continuous care patients. The ADM stated she did not use any other data and/or quality measure (tools used to quantify the performance of healthcare providers and facilities to ensure patients receive high-quality care) to determine what project the QAPI committee will work on.During an interview on 5/17/2025 at 3:39 PM, with the ADM, the ADM stated the QAPI’s schedule every 3rd quarter of the year was focused on the hospice care of general inpatient care. The ADM stated the facility does not have any general inpatient cases, and they never had one. The ADM stated because the general inpatient care project was included in the QAPI program before and it became habitual for them that the QAPI committee just continue doing it, even if it had zero result because of no inpatient cases. During an interview on 5/17/2025 at 3:39 PM, The ADM stated she does not have any data gathering or tracking process to obtain information and/or identify any issue or improvement needed on the hospice services being provided to the patients.During an interview on 5/18/2025 at 11:08 AM, the ADM stated the QAPI report does not have analysis of the information gathered, no recommendation or action plan based on the information gathered.During a review of the facility’s policy and procedure (P&P) titled, “Improving Organizational Performance/Quality Assessment and Performance Improvement,” dated April 2012, the P&P indicated, “The hospice shall have an organized system for assessing and improving the quality of care and services. The QAPI shall be designed to improve performance on a systematic and continuous basis. The system shall consist of planned and measurable mechanisms for data collection, analysis and process for the improvement within the specific time frames. The hospice shall implement performance improvement processes that routinely assess and improve all services provided and by written agreement. All personnel will be active participants in hospice quality assessment performance improvement (QAPI) activities. Set expectations for performance improvement and manage processes to improve organization. Adopt a scientific, problem-solving data driven approach to quality assessment and performance improvement (QAPI). The scientific, problem-solving approach will include planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume or problem prone areas. These may include risk management, such as adverse pain events and medication management, utilization management, quality control, patient safety program, palliative outcomes tracking such as pain control. Provide hospice personnel training in effective approaches and methods of assessment and improvement.”

Based on observation, interview, and record review, the facility failed to provide documented evidence that the facility’s Quality Assurance and Performance Improvement (QAPI, a data driven proactive approach to improvement used to ensure services are meeting quality standards) improvement project activities were based on the needs of the hospice patients and staff, and performance of the hospice services and operations for nine of nine sampled  patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). This failure resulted in the facility’s QAPI program to not have a system that effectively assess and identify needs for improvement in providing quality and safe care that may have contributed to the lack of patient care coordination for assessment of the patients’ needs when,  Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, were not available for the patients to use when needed. In addition, this failure has a potential to result in an inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death to the patients. --- Findings:a. During a review of Patient 1’s Personal Information Record, the record indicated Patient 1’s Start of Care (SOC) was 10/30/2023, with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time) and Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do). During a review of Patient 1’s “Current Treatment/Medication/DME List,” dated 4/1/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. b. During a review of Patient 2’s Personal Information Record, the record indicated Patient 2’s SOC was 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia, dementia (loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult). During a review of Patient 2’s “Current Treatment/Medication/DME List,” dated 11/7/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient and oxygen 2 to 5 liter per minute (lpm) via nasal cannula as needed for shortness of breath. c. During a review of Patient 3’s Personal Information Record, the record indicated Patient 3’s SOC was 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip). During a review of Patient 3’s “Current Treatment/Medication/DME List,” dated 10/21/2023, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. d. During a review of Patient 4’s Personal Information Record, the record indicated Patient 4’s SOC was 3/26/2025, with primary diagnosis of metabolic encephalopathy with Alzheimer’s Disease. During a review of Patient 4’s “Current Treatment/Medication/DME List,” dated 3/26/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. e. During a review of Patient 5’s Personal Information Record, the record indicated Patient 5’s SOC was 2/12/2025, with primary diagnosis of metabolic encephalopathy with healed traumatic fracture (healed bone break). During a review of Patient 5’s “Current Treatment/Medication/DME List,” dated 2/12/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. f. During a review of Patient 6’s Personal Information Record, the record indicated Patient 6’s SOC was 12/6/2024, with primary diagnosis of metabolic encephalopathy with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering [myelin] on nerve fibers in the brain and spinal cord). During a review of Patient 6’s “Current Treatment/Medication/DME List,” dated 12/6/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. g. During a review of Patient 7’s Personal Information Record, the record indicated Patient 7’s SOC was 8/15/2024, with primary diagnosis of metabolic encephalopathy, Alzheimer’s Disease, dementia (loss of thinking, remembering and reasoning skill) and chronic back/legs pain (long-term pain to back and legs). During a review of Patient 7’s “Current Treatment/Medication/DME List,” dated 8/15/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. h. During a review of Patient 8’s Personal Information Record, the record indicated Patient 8’s SOC was 6/16/2024, with metabolic encephalopathy and dementia. During a review of Patient 8’s “Current Treatment/Medication/DME List,” dated 6/16/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. i. During a review of Patient 9’s Personal Information Record, the record indicated Patient 9’s SOC was 4/4/2024, with diagnosis of metabolic encephalopathy, type 2 diabetes mellitus (a long-term condition in which the body does not use insulin [a hormone that helps glucose (sugar) from food enter the cells for energy] properly or produce enough insulin).  During a review of Patient 9’s “Current Treatment/Medication/DME List,” dated 4/4/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient.During an observation on 5/15/2025 at 2:01 pm, with the Visiting Registered Nurse (VRN), Patient 2 was observed in her room, lying in bed and was conversant with the VRN. No oxygen machine was observed inside Patient 2’s room. During a concurrent observation and interview, on 5/15/2025 at 2:39 pm, with Medication Tech 1 (MT 1), MT 1 was observed looking for Patient 1, Patient 2, and Patient 3’s comfort pack medications in the medication cart. MT 1 stated she did not have Patient 1, Patient 2, and Patient 3’s comfort pack medications.During a concurrent observation and interview, on 5/16/25 at 2:24 pm, with the VRN, the VRN was observed looking for Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications in the medication cart. The VRN stated Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications were missing and does not have those medications.During an interview on 5/17/2025 at 3:35 PM, with the Administrator (ADM), the ADM stated she was a member and leader of the QAPI. The ADM stated the QAPI quarterly report was being submitted and reported during the Interdisciplinary Group (IDG, a team of healthcare professionals from different disciplines who work collaboratively to provide comprehensive and individualized care for hospice patients and their families) meeting. The ADM stated the QAPI committee meeting was only done once a year, at the end of year (annual) with Governing Body (GB, is responsible for the overall management of the hospice, including its legal, financial, and operational aspects. The GB ensures the facility adheres to regulations, provides high quality care, and continuously improves its services) meeting. During a concurrent interview and record review, on 5/17/2025 at 3:38 PM, with the ADM, the facility’s “QAPI agenda and minutes” for 12/2024 was reviewed. The ADM stated the purpose of QAPI was to review the care areas for the facility to focus on. The ADM stated she was the one who decides what projects the QAPI committee would need to work on. The ADM stated the QAPI project was based on what the previous QAPI had been doing since 2015.  The ADM stated the committee was aware of all scheduled QAPI projects and agreed to proceed as scheduled. During an interview on 5/17/2025 at 3:38 PM, the ADM stated the facility’s QAPI project were scheduled quarterly. The ADM stated on the first (1st) quarter (January to March) the QAPI project was focus on family satisfaction, the second (2nd) quarter (April to June) the QAPI project was infection control, the third (3rd) quarter (July to September) the QAPI project was focus on their general inpatient care, and the fourth (4th) quarter (October to December) the QAPI project was on the documentation compliance for continuous care patients. The ADM stated she did not use any other data and/or quality measure (tools used to quantify the performance of healthcare providers and facilities to ensure patients receive high-quality care) to determine what project the QAPI committee will work on.During a concurrent interview and record review, on 5/17/2025 at 3:39 PM, with the ADM, the “QAPI agenda and minutes” for 12/2024 was reviewed. The QAPI minutes had no documentation of QAPI report and analysis of the scheduled QAPI project from January 2024 through May 2025. The ADM stated the QAPI’s schedule every 3rd quarter of the year was focused on the hospice care of general inpatient care. The ADM stated the facility does not have any general inpatient cases, and they never had one. The ADM stated because the general inpatient care project was included in the QAPI program before and it became habitual for them that the QAPI committee just continue doing it, even if it had zero result because of no inpatient cases. During an interview on 5/17/2025 at 3:39 PM, The ADM stated she does not have any data gathering or tracking process to obtain information and/or identify any issue or improvement needed on the hospice services being provided to the patients.During a review of the facility’s policy and procedure (P&P) titled, “Improving Organizational Performance/Quality Assessment and Performance Improvement,” dated April 2012, the P&P indicated, “The hospice shall have an organized system for assessing and improving the quality of care and services. The QAPI shall be designed to improve performance on a systematic and continuous basis. The system shall consist of planned and measurable mechanisms for data collection, analysis and process for the improvement within the specific time frames. The hospice shall implement performance improvement processes that routinely assess and improve all services provided and by written agreement. All personnel will be active participants in hospice quality assessment performance improvement (QAPI) activities. Set expectations for performance improvement and manage processes to improve organization. Adopt a scientific, problem-solving data driven approach to quality assessment and performance improvement (QAPI). The scientific, problem-solving approach will include planning for performance improvement with integration of information from other relevant activities that focus on high risk, high volume or problem prone areas. These may include risk management, such as adverse pain events and medication management, utilization management, quality control, patient safety program, palliative outcomes tracking such as pain control. Provide hospice personnel training in effective approaches and methods of assessment and improvement.”

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the condition of participation (CoP-a set of minimum professional standards all home health agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Organizational Environment were met as follows: --- 1. The facility failed to demonstrate a process and provide documented evidence of the Governing Body (GB, a group of individuals who have responsibility for the overall management and operations, such as the legal, financial aspects of the organization, including oversight of the patient care, fiscal operations, and quality improvement activities) had knowledge and involvement in the facility’s quality assessment performance improvement (QAPI, a data-driven approach that combines quality and performance improvement to enhance healthcare quality, safety, and compliance) program to assess processes of care, hospice services (a specialized form of end-of-life care that provides comfort, support, and medical assistance to terminally ill patients and their families that focuses on improving the quality of life and easing suffering during the final stages of life), and operations for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).This failure resulted in the facility GB’s lack of responsibility and oversight in the facility’s QAPI to ensure the program have a system that effectively assess and identify needs for improvement in providing quality and safe care that may have contributed to the lack of patient care coordination for assessment of the patients’ needs when,  Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, were not available for the patients to use when needed. In addition, this failure has a potential to result in an inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death to the patients. (Refer to L651)2. The facility failed to ensure the availability of the comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and the oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, as needed by the patients for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).This failure had the potential to result in significant discomfort and distress for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9, and are likely to suffer unmanaged pain or may die in severe pain or distress and agitation which can lead to emergency hospitalization that may contribute to unavoidable traumatic death. In addition, the patients are likely to experience undignified death and exposed to an unsafe environment. (Refer to L653)3. The facility failed to provide documented evidence of the Director of Patient Care Services (DPCS, responsible for overseeing the overall operations and ensuring the delivery of high-quality, compassionate care to patients and their families) Designee’s orientation and training regarding the specific job duties of a DPCS. This failure had the potential to result in the lack of coordination of care, not meeting the hospice patients’ needs, and decline in quality of care and services for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). (Refer to L662)4. The facility failed to ensure the Director of Patient Care Services (DPCS, responsible for overseeing the overall operations and ensuring the delivery of high-quality, compassionate care to patients and their families) Designee has the required skills, competencies, and experience in hospice (provides specialized care to terminally ill patients focusing on comfort and quality of life, rather than a cure). This failure had the potential to result in lack of compliance with the regulations and the inability to oversee the delivery of high-quality and compassionate care to nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). (Refer to L663)The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (relating to rules or laws which have been formally written down) mandated compliance with the Federal regulations for Organization and Administration of Services to ensure provision of the highest quality of care for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9 who were assessed to receive hospice care services.

Based on observation, interview, and record review, the facility failed to demonstrate a process and provide documented evidence of the Governing Body (GB, a group of individuals who have responsibility for the overall management and operations, such as the legal, financial aspects of the organization, including oversight of the patient care, fiscal operations, and quality improvement activities) had knowledge and involvement in the facility’s quality assessment performance improvement (QAPI, a data-driven approach that combines quality and performance improvement to enhance healthcare quality, safety, and compliance) program to assess processes of care, hospice services (a specialized form of end-of-life care that provides comfort, support, and medical assistance to terminally ill patients and their families that focuses on improving the quality of life and easing suffering during the final stages of life), and operations for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).This failure resulted in the facility GB’s lack of responsibility and oversight in the facility’s QAPI to ensure the program have a system that effectively assess and identify needs for improvement in providing quality and safe care that may have contributed to the lack of patient care coordination for assessment of the patients’ needs when,  Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, were not available for the patients to use when needed. In addition, this failure has a potential to result in an inadequate quality of care, unsafe patient care, and increased risk of medical errors and adverse event that can lead to emergency hospitalization and may contribute to an avoidable traumatic death to the patients.  On 5/18/2025, at 5:14 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the Administrator (ADM) for failing to ensure the governing body (GB – a group of individuals who have responsibility for the overall management and operations, such as the legal, financial aspects of the organization, including oversight of the patient care, fiscal operations, and quality improvement activities) failed to demonstrate and provide documented evidence of knowledge and involvement in the hospice agency’s quality assessment performance improvement (QAPI – a data-driven approach that combines quality and performance improvement to enhance healthcare quality, safety, and compliance) program for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).On 6/6/2025 at 1:00 p.m., after confirming the facility's implementation of the immediate corrective actions from the accepted IJ removal plan, the Department  removed the Immediate Jeopardy while onsite, in the presence of the Office Manager. --- Findings: a. During a review of Patient 1’s Personal Information Record, the record indicated Patient 1’s Start of Care (SOC) was 10/30/2023, with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time) and Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do). During a review of Patient 1’s “Current Treatment/Medication/DME List,” dated 4/1/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. b. During a review of Patient 2’s Personal Information Record, the record indicated Patient 2’s SOC was 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia, dementia (loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult). During a review of Patient 2’s “Current Treatment/Medication/DME List,” dated 11/7/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient and oxygen 2 to 5 liter per minute (lpm) via nasal cannula as needed for shortness of breath. c. During a review of Patient 3’s Personal Information Record, the record indicated Patient 3’s SOC was 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip). During a review of Patient 3’s “Current Treatment/Medication/DME List,” dated 10/21/2023, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. d. During a review of Patient 4’s Personal Information Record, the record indicated Patient 4’s SOC was 3/26/2025, with primary diagnosis of metabolic encephalopathy with Alzheimer’s Disease. During a review of Patient 4’s “Current Treatment/Medication/DME List,” dated 3/26/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. e. During a review of Patient 5’s Personal Information Record, the record indicated Patient 5’s SOC was 2/12/2025, with primary diagnosis of metabolic encephalopathy with healed traumatic fracture (healed bone break). During a review of Patient 5’s “Current Treatment/Medication/DME List,” dated 2/12/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. f. During a review of Patient 6’s Personal Information Record, the record indicated Patient 6’s SOC was 12/6/2024, with primary diagnosis of metabolic encephalopathy with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering [myelin] on nerve fibers in the brain and spinal cord). During a review of Patient 6’s “Current Treatment/Medication/DME List,” dated 12/6/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. g. During a review of Patient 7’s Personal Information Record, the record indicated Patient 7’s SOC was 8/15/2024, with primary diagnosis of metabolic encephalopathy, Alzheimer’s Disease, dementia (loss of thinking, remembering and reasoning skill) and chronic back/legs pain (long-term pain to back and legs). During a review of Patient 7’s “Current Treatment/Medication/DME List,” dated 8/15/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. h. During a review of Patient 8’s Personal Information Record, the record indicated Patient 8’s SOC was 6/16/2024, with metabolic encephalopathy and dementia. During a review of Patient 8’s “Current Treatment/Medication/DME List,” dated 6/16/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. i. During a review of Patient 9’s Personal Information Record, the record indicated Patient 9’s SOC was 4/4/2024, with diagnosis of metabolic encephalopathy, type 2 diabetes mellitus (a long-term condition in which the body does not use insulin [a hormone that helps glucose (sugar) from food enter the cells for energy] properly or produce enough insulin).  During a review of Patient 9’s “Current Treatment/Medication/DME List,” dated 4/4/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient.During an observation on 5/15/2025 at 2:01 pm, with the Visiting Registered Nurse (VRN), Patient 2 was observed in her room, lying in bed and was conversant with the VRN. No oxygen machine was observed inside Patient 2’s room. During a concurrent observation and interview, on 5/15/2025 at 2:39 pm, with Medication Tech 1 (MT 1), MT 1 was observed looking for Patient 1, Patient 2, and Patient 3’s comfort pack medications in the medication cart. MT 1 stated she did not have Patient 1, Patient 2, and Patient 3’s comfort pack medications.During a concurrent observation and interview, on 5/16/25 at 2:24 pm, with the VRN, the VRN was observed looking for Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications in the medication cart. The VRN stated Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications were missing and does not have those medications.During a review of the “Governing Body Minutes,” dated 12/30/2024, the minutes agenda had no documented evidence that the QAPI was discuss and QAPI report was given to the GB. During an interview on 5/17/2025 at 3:55 PM, with the administrator (ADM), the ADM stated, she was a member of the GB, and she was the one who leads the GB. The ADM stated the GB last meeting was held on 12/2024, and the next meeting will be on 12/2025 because the GB meets only once, at the end of the year. The ADM stated during the GB annual meeting, the agenda was about budget approval, policy and procedure (P&P) review, and QAPI report. The ADM stated the GB was the one responsible for the facility’s performance in providing quality of care and patient safety.  The ADM stated she has a Master of Social Work (MSW – a graduate level degree that provides advanced training and education in the field of social work) by profession. The ADM stated she was in charge of the facility operation and the Director of Patient Care Services (DPCS) was in charge of the clinician license staff and patient care. The ADM stated the DPCS was currently on vacation and the Designee can be interviewed.During an interview on 5/17/2025 at 4:57 PM, with the Designee, the Designee stated, she has experience as a Designee because she was currently a DPCS of another facility. The Designee stated she only covers the facility as Designee if the DPCS was not available. The Designee stated the facility’s DPCS was currently on vacation, and she was covering.  The Designee stated her responsibility to the facility was focused on patient care and management of the nursing care and what needs to be done for the patients.  The Designee stated she did not receive a hand-off from the DPCS. The Designee stated she should have been given a report or hand-off from the DPCS before leaving on vacation, to know what she was dealing with and what she needs to follow up. The Designee stated she needs to know the patients’ condition and what she needed to do while covering for the DPCS.During an interview on 5/18/2025 at 11:08 AM, the ADM stated she only provides GB the QAPI reports at the end of the year. The ADM stated she only gave the GB all the information she gathered on a quarterly basis about what the QAPI was working on. The ADM stated the report she provided to the GB had no analysis of the information gathered, no recommendation or action plans based on the information gathered. The ADM was not able to provide documentation that the GB was provided QAPI reports on a quarterly basis and annually, at the end of the year.During a review of the hospice agency’s policy and procedure (P&P) titled, “Governing Body,” revised April 2012, the P&P indicated, “…Relevant findings of performance improvement activities are consistently provided to the Governing Body…Other information relevant to the quality of patient care (i.e., unusual occurrences in care delivered) is consistently provided through a defined process.  The Governing Body will ensure that at least the following are members of a group designated for operating the quality assessment and performance improvement program:1. The Administrator2. The hospice Medical Director3. The Patient Care Coordinator or Director of Patient Care Services4.  A hospice Social Worker of Counselor…The Governing Body will authorize adequate resources and support to establish and maintain an organization-wide quality assessment and performance improvement program (QAPI).  Information related to the performance improvement program will be provided to the Governing Body on a quarterly basis…The Governing Body must ensure that the QAPI program:a.  Addresses priorities for improved quality of care and patient safetyb. Reflects the complexity of the organization and servicesc. Involve all hospice services, including those under contract or arrangementd. Focuses on indicators related to improved palliative outcomes…Take actions to demonstrate improvement in hospice performance…”

Based on observation, interview, and record review, the facility failed to ensure the availability of the comfort pack medications (such as morphine [narcotic analgesic, also known as an opioid, that works by affecting the central nervous system to relieve pain], lorazepam [a benzodiazepine that works in the brain to relieve symptoms of anxiety], and ondansetron [used to prevent nausea and vomiting] and the oxygen concentrator (a device that increases the concentration of oxygen in air commonly used by individuals who need extra oxygen due to breathing difficulties or lung conditions), as ordered by the physician, as needed by the patients for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9).This failure had the potential to result in significant discomfort and distress for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9, and are likely to suffer unmanaged pain or may die in severe pain or distress and agitation which can lead to emergency hospitalization that may contribute to unavoidable traumatic death. In addition, the patients are likely to experience undignified death and exposed to an unsafe environment.On 5/16/2025 at 8:04 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the Hospice Agency’s (HA- an agency that specializes in providing medical care for people who are expected to live six months or less) Visiting Registered Nurse (VRN) with the Administrator (Admin) on the phone for failing to ensure that the physician ordered comfort pack medications (a set of medicines kept at home. It is used for fast relief when pain, fear or sickness become worse in hospice patients) was available to the patients as ordered.On 5/19/25 at 4:49 p.m. while on site and after verifying the implementation of the accepted IJ removal plan (IJRP- includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death of a patient likely), the survey team removed the IJ in the presence of the Administrator. --- Findings: a. During a review of Patient 1’s Personal Information Record, the record indicated Patient 1’s Start of Care (SOC) was 10/30/2023, with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time) and Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do). During a review of Patient 1’s “Current Treatment/Medication/DME List,” dated 4/1/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. b. During a review of Patient 2’s Personal Information Record, the record indicated Patient 2’s SOC was 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia, dementia (loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult). During a review of Patient 2’s “Current Treatment/Medication/DME List,” dated 11/7/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient and oxygen 2 to 5 liter per minute (lpm) via nasal cannula as needed for shortness of breath. c. During a review of Patient 3’s Personal Information Record, the record indicated Patient 3’s SOC was 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip). During a review of Patient 3’s “Current Treatment/Medication/DME List,” dated 10/21/2023, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. d. During a review of Patient 4’s Personal Information Record, the record indicated Patient 4’s SOC was 3/26/2025, with primary diagnosis of metabolic encephalopathy with Alzheimer’s Disease. During a review of Patient 4’s “Current Treatment/Medication/DME List,” dated 3/26/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. e. During a review of Patient 5’s Personal Information Record, the record indicated Patient 5’s SOC was 2/12/2025, with primary diagnosis of metabolic encephalopathy with healed traumatic fracture (healed bone break). During a review of Patient 5’s “Current Treatment/Medication/DME List,” dated 2/12/2025, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. f. During a review of Patient 6’s Personal Information Record, the record indicated Patient 6’s SOC was 12/6/2024, with primary diagnosis of metabolic encephalopathy with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering [myelin] on nerve fibers in the brain and spinal cord). During a review of Patient 6’s “Current Treatment/Medication/DME List,” dated 12/6/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. g. During a review of Patient 7’s Personal Information Record, the record indicated Patient 7’s SOC was 8/15/2024, with primary diagnosis of metabolic encephalopathy, Alzheimer’s Disease, dementia (loss of thinking, remembering and reasoning skill) and chronic back/legs pain (long-term pain to back and legs). During a review of Patient 7’s “Current Treatment/Medication/DME List,” dated 8/15/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. h. During a review of Patient 8’s Personal Information Record, the record indicated Patient 8’s SOC was 6/16/2024, with metabolic encephalopathy and dementia. During a review of Patient 8’s “Current Treatment/Medication/DME List,” dated 6/16/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient. i. During a review of Patient 9’s Personal Information Record, the record indicated Patient 9’s SOC was 4/4/2024, with diagnosis of metabolic encephalopathy, type 2 diabetes mellitus (a long-term condition in which the body does not use insulin [a hormone that helps glucose (sugar) from food enter the cells for energy] properly or produce enough insulin).  During a review of Patient 9’s “Current Treatment/Medication/DME List,” dated 4/4/2024, the list indicated a physician’s order for comfort pack medications (morphine, lorazepam, and ondansetron) as needed by the patient.During an observation on 5/15/2025 at 2:01 pm, with the Visiting Registered Nurse (VRN), Patient 2 was observed in her room, lying in bed and was conversant with the VRN. No oxygen machine was observed inside Patient 2’s room. During a concurrent observation and interview, on 5/15/2025 at 2:39 pm, with Medication Tech 1 (MT 1), MT 1 was observed looking for Patient 1, Patient 2, and Patient 3’s comfort pack medications in the medication cart. MT 1 stated she did not have Patient 1, Patient 2, and Patient 3’s comfort pack medications.During a concurrent observation and interview, on 5/16/25 at 2:24 pm, with the VRN, the VRN was observed looking for Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications in the medication cart. The VRN stated Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9’s comfort pack medications were missing and does not have those medications.During an interview on 5/16/25 at 4:26 pm, the VRN stated she was the one responsible in coordinating the care and reviewing the patients’ medication during the Interdisciplinary Group (IDG, a team of healthcare professionals from different disciplines who work collaboratively to provide comprehensive and individualized care for hospice patients and their families) meetings. The VRN stated she discuss in the IDG meetings any concern or issue with the patients’ medications including the efficacy of the treatment, new medication, and any need for change or discontinuation of the medications. The VRN stated she did not discuss and consult the physician during the IDG meetings regarding the patients’ comfort packs medication if needed to change or discontinued.During an interview on 5/16/2025 at 6:13 pm, with the VRN, the VRN stated it was her responsibility to review the patient’s care plan and ensure the interventions were being implemented. The VRN stated it was her responsibility to ensure Patient 2’s oxygen concentrator was available for use as needed by the patient.During a review of the facility’s policy and procedure (P&P) titled, “MEDICATION PROFILE,” revised in April 2013, the P&P indicated, “Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications...The drug regimen review will be completed by the interdisciplinary group in consultation with an individual with education and training in hospice and palliation drug management to ensure that drugs and biological meet each patient’s needs…”

Based on interview and record review, the facility failed to provide documented evidence of the Director of Patient Care Services (DPCS, responsible for overseeing the overall operations and ensuring the delivery of high-quality, compassionate care to patients and their families) Designee’s orientation and training regarding the specific job duties of a DPCS. This failure had the potential to result in the lack of coordination of care, not meeting the hospice patients’ needs, and decline in quality of care and services for nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). --- Findings: During an interview on 5/17/2025 at 4:57 PM, with the Designee, the Designee stated she was involved in the facility as a DPCS Designee when the DPCS is not available. The Designee stated her role as the Designee was to oversee patient care and manage patient care needs.   During a concurrent interview and record review, on 5/19/2025 at 2:21 PM, with the Designee, the Designee’s “New Hire Orientation Packet,” dated 6/4/2021 was reviewed.  The packet had no documented evidence of the Designee's orientation for the DPCS roles and responsibilities. The Designee stated she does not remember if she received any training regarding the role of a DPCS Designee. The Designee stated she made a mistake of taking her role as a Designee lightly and never performed any patient visits since she started working for the facility. The Designee stated she did not have any experience as a hospice Registered Nurse (RN), and she had no knowledge on the hospice services.  During a review of the facility’s policy and procedure (P&P) titled, “Job Description,” revised in April 2013, the P&P indicated, “Job Title/Position:  Clinical Director/Director of Patient Care Services…The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services.  The Clinical Director/ Director of Patient Care Services establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy…ESSENTIAL JOB FUNCTIONS/RESPONSIBILITIES…Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel. Provides guidance and counseling to coordinators and Clinical Supervisors/Nursing Supervisors to assist them in continually improving all aspects of hospice care services, provided through organization personnel…Provides help in assessment, planning, implementation and evaluation of patient and family/caregiver care to all clinical personnel as indicated…Assists with the evaluation of organization performance via quality assessment performance improvement program, productivity, quarterly, and annual reviews. Assures for the quality and safe delivery of hospice services provided through the Organization. Assists in the development of organization goals.  Develops, recommends, and administers Organization policies and procedures. Assures compliance with all local, state, and federal laws regarding licensure and certification of organization personnel and, maintains compliance to the Joint Commission Home Care standards…In the temporary absence (in excess of twenty [20] consecutive working days) of the Director of Patient Care Services, a Registered Nurse shall be designated, in writing, as responsible for fulfilling the duties of the Director of Patient Care Services.”a. During a review of Patient 1’s Personal Information Record, the record indicated Patient 1’s Start of Care (SOC) was 10/30/2023, with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time) and Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do). b. During a review of Patient 2’s Personal Information Record, the record indicated Patient 2’s SOC was 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia, dementia (loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult). c. During a review of Patient 3’s Personal Information Record, the record indicated Patient 3’s SOC was 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip). d. During a review of Patient 4’s Personal Information Record, the record indicated Patient 4’s SOC was 3/26/2025, with primary diagnosis of metabolic encephalopathy with Alzheimer’s Disease. e. During a review of Patient 5’s Personal Information Record, the record indicated Patient 5’s SOC was 2/12/2025, with primary diagnosis of metabolic encephalopathy with healed traumatic fracture (healed bone break). f. During a review of Patient 6’s Personal Information Record, the record indicated Patient 6’s SOC was 12/6/2024, with primary diagnosis of metabolic encephalopathy with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering [myelin] on nerve fibers in the brain and spinal cord). g. During a review of Patient 7’s Personal Information Record, the record indicated Patient 7’s SOC was 8/15/2024, with primary diagnosis of metabolic encephalopathy, Alzheimer’s Disease, dementia (loss of thinking, remembering and reasoning skill) and chronic back/legs pain (long-term pain to back and legs). h. During a review of Patient 8’s Personal Information Record, the record indicated Patient 8’s SOC was 6/16/2024, with metabolic encephalopathy and dementia. i. During a review of Patient 9’s Personal Information Record, the record indicated Patient 9’s SOC was 4/4/2024, with diagnosis of metabolic encephalopathy, type 2 diabetes mellitus (a long-term condition in which the body does not use insulin [a hormone that helps glucose (sugar) from food enter the cells for energy] properly or produce enough insulin).

Based on interview and record review, the facility failed to ensure the Director of Patient Care Services (DPCS, responsible for overseeing the overall operations and ensuring the delivery of high-quality, compassionate care to patients and their families) Designee has the required skills, competencies, and experience in hospice (provides specialized care to terminally ill patients focusing on comfort and quality of life, rather than a cure). This failure had the potential to result in lack of compliance with the regulations and the inability to oversee the delivery of high-quality and compassionate care to nine of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 9). --- Findings:During an interview on 5/17/2025 at 4:57 PM, with the Designee, the Designee stated she was involved in the facility as a DPCS Designee when the DPCS is not available. The Designee stated her role as the Designee was to oversee patient care and manage patient care needs.   During a concurrent interview and record review, on 5/19/2025 at 2:21 PM, with the Designee, the Designee’s employee file indicated the Designee was hired by the facility as a DPCS Designee on 6/4/202.  The Designee stated she does not remember if she received any training regarding the role of a DPCS Designee. The Designee stated she made a mistake of taking her role as a Designee lightly and never performed any patient visits since she started working for the facility. The Designee stated she did not have any experience as a hospice Registered Nurse (RN), and she had no knowledge on the hospice services.  During a review of the facility’s policy and procedure (P&P) titled, “Job Description,” revised in April 2013, the P&P indicated, “Job Title/Position:  Clinical Director/Director of Patient Care Services…The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services.  The Clinical Director/ Director of Patient Care Services establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy…. POSITION QUALIFICATIONS…Three years of management experience within the last five years in a hospice or related health care organization, at least one year of which was a supervisory or administrative capacity… A registered nurse with four years experience within the last five years in a hospice agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity…”a. During a review of Patient 1’s Personal Information Record, the record indicated Patient 1’s Start of Care (SOC) was 10/30/2023, with primary diagnosis of acute respiratory failure with hypoxia (Respiratory failure is a condition where there’s not enough oxygen or too much carbon dioxide in your body over time) and Alzheimer’s Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest things you have to do). b. During a review of Patient 2’s Personal Information Record, the record indicated Patient 2’s SOC was 11/4/2024, with primary diagnosis of acute respiratory failure with hypoxia, dementia (loss of thinking, remembering and reasoning skills), and asthma (a long-lasting disease of the airways that makes it breathing difficult). c. During a review of Patient 3’s Personal Information Record, the record indicated Patient 3’s SOC was 10/21/2023, with primary diagnosis of metabolic encephalopathy (brain is not working correctly because of problems with the body’s chemical processes) with displaced intertrochanteric fracture of left femur (broken left hip). d. During a review of Patient 4’s Personal Information Record, the record indicated Patient 4’s SOC was 3/26/2025, with primary diagnosis of metabolic encephalopathy with Alzheimer’s Disease. e. During a review of Patient 5’s Personal Information Record, the record indicated Patient 5’s SOC was 2/12/2025, with primary diagnosis of metabolic encephalopathy with healed traumatic fracture (healed bone break). f. During a review of Patient 6’s Personal Information Record, the record indicated Patient 6’s SOC was 12/6/2024, with primary diagnosis of metabolic encephalopathy with cerebrovascular accident (CVA) and multiple sclerosis (MS a condition where the body’s immune system mistakenly attacks and damages the protective covering [myelin] on nerve fibers in the brain and spinal cord). g. During a review of Patient 7’s Personal Information Record, the record indicated Patient 7’s SOC was 8/15/2024, with primary diagnosis of metabolic encephalopathy, Alzheimer’s Disease, dementia (loss of thinking, remembering and reasoning skill) and chronic back/legs pain (long-term pain to back and legs). h. During a review of Patient 8’s Personal Information Record, the record indicated Patient 8’s SOC was 6/16/2024, with metabolic encephalopathy and dementia. i. During a review of Patient 9’s Personal Information Record, the record indicated Patient 9’s SOC was 4/4/2024, with diagnosis of metabolic encephalopathy, type 2 diabetes mellitus (a long-term condition in which the body does not use insulin [a hormone that helps glucose (sugar) from food enter the cells for energy] properly or produce enough insulin).

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the condition of participation (CoP-a set of minimum professional standards all hospice agencies must meet to participate in Medicare [federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that provides health coverage for some people with limited income and resources] government programs) for Clinical Records were not met as follows: --- The facility failed to ensure the required physician recertification of terminal illness was met for seven of nine sampled patient (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, and Patient 9) when, the Physician or the Medical Director (MD) did not performed a face-to-face encounter for seven of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, and Patient 9) prior to signing the “Certification of Terminal Illness (CTI, a document that a physician completes to confirm a patient's life expectancy is six months or less if their illness progresses as expected),” prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care. This failure had the potential to result in the patients not meeting the recertification of terminal illness eligibility requirement. (Refer to L676).The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (relating to rules or laws which have been formally written down) mandated compliance with the Federal regulations for Clinical Records to ensure provision of the highest quality of care for Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, and Patient 9 who were assessed to receive hospice care services.

Based on interview and record review, the facility failed to ensure the required physician recertification of terminal illness was met for seven of nine sampled patient (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, and Patient 9) when, the Physician or the Medical Director (MD) did not performed a face-to-face encounter for seven of nine sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, and Patient 9) prior to signing the “Certification of Terminal Illness (CTI - a document that a physician completes to confirm a patient's life expectancy is six months or less if their illness progresses as expected),” prior to, but no more than 30 calendar days prior to, the 3rd benefit period recertification, and every benefit period recertification thereafter, to gather clinical findings to determine continued eligibility for hospice care. This failure had the potential to result in the patients not meeting the recertification of terminal illness eligibility requirement.On 5/19/2025 at 7:01 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient) in the presence of the Hospice Agency’s (HA- an agency that specializes in providing medical care for people who are expected to live six months or less) Administrator (Admin) for failing to ensure the required Physician conducted a face to face assessment prior to signing the certification of terminal illness (the certification must specify that the individual's prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course) for seven of nine sampled patients.On 5/19/25 at 9:24 p.m. while on site and after verifying the implementation of the accepted IJ removal plan (IJRP- includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death of a patient likely), the survey team removed the IJ in the presence of the Administrator. --- Findings:During an interview on 5/17/2025 at 3:08 PM with the MD, the MD stated his main responsibility was to have an oversight of the hospice patients and attend the Interdisciplinary Group (IDG, the team responsible for the holistic care of the hospice beneficiary) meeting. The MD stated he does not visit the hospice patients, it was the patient’s attending physician who comes and visit their patients, and he only gets report from the attending physicians. The MD stated he was only available to answer questions or if the hospice patients needed orders or have concerns that they can call him.  During an interview on 5/19/2025 at 3:07 PM with the MD, the MD stated he does not visit the hospice patients and that it was the attending physician of the patients who comes and visits the patients. The MD was made aware that for Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, and Patient 9’s CTI, indicated a face-to-face encounter was signed by him. The MD was not able to give an answer as to why it was signed by him, if he was not visiting the hospice patients. The MD stated he was given a copy of the Medical Director’s role and responsibilities and that he was aware of his role and responsibilities as the MD of the facility.  During an interview on 5/19/2025 at 3:28 PM, with the Visiting Registered Nurse (VRN), the VRN stated the hospice recertification was every 2 months. The VRN stated during recertification of the hospice patients, she completes the data and current status of the patient, and the MD comes and visits the hospice patient, scheduled for recertification.  The VRN stated it was the MD who she contacts to do the recertification of the hospice patient, and she only contacts the patient’s attending physician if the MD was not available, which rarely happens.During an interview on 5/19/2025 at 3:28 PM, the VRN stated when she comes and does her hospice visits, there were times that she sees the MD in the facility visiting other patients. The VRN stated she could not confirm if he was there to see the hospice patients and if he was there for a recertification visit of the hospice patients.  The VRN stated the MD was reminded of the hospice patients recertification schedule and she will be told by the MD that he will come and visit the patients, but she had no documentation that the visits occurred.  The VRN stated she relies on the MD’s CTI and having the MD signed the document, indicated a face-to-face encounter was conducted by the MD.a. During a review of Patient 1’s “Personal Information,” the record indicated Patient 1’s start of care (SOC) was 10/3/2023, with a primary diagnosis of acute respiratory failure (a sudden inability of the lungs to provide enough oxygen to the body or to remove enough carbon dioxide, leading to life-threatening conditions) with hypoxia (a condition where there is an inadequate supply of oxygen to the body's tissues) and Alzheimer’s dementia (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline).   During a review of Patient 1’s “CTI #9 (9th benefit period) for 4/22/2025 to 6/20/2025”, the CTI indicated a face-to-face encounter was signed by the MD on 4/21/2025, attesting/confirming, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.” b. During a review of Patient 2’s “Personal Information,” the record indicated Patient 2’s SOC was 11/4/2024, with a primary diagnosis of acute respiratory failure with hypoxia, dementia (a general term for a group of brain disorders that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), and persistent asthma (chronic respiratory condition characterized by inflammation and narrowing of the airways).  During a review of Patient 2’s “CTI #4 (4th benefit period) for 4/6/2025 to 6/4/2025,” the CTI indicated a face-to-face encounter was signed by the MD on 4/21/2025, attesting/confirming, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.”c. During a review of Patient 3’s “Personal Information,” the record indicated Patient 3’s SOC was 10/21/2023, with a primary diagnosis of metabolic encephalopathy (a condition that affects brain function due to an imbalance in the body's metabolism) and displaced intertrochanteric fracture of left femur (a type of hip fracture where the break in the bone has shifted or separated from its normal position).  During a review of Patient 3’s “CTI #9 for 4/13/2025 to 6/11/2025,” the CTI indicated a face-to-face encounter was signed by the MD on 4/11/2025, attesting/confirming, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.”d. During a review of Patient 6’s “Personal Information,” the record indicated Patient 6’s SOC was 12/6/2023, with a primary diagnosis of metabolic encephalopathy with CVA (cerebrovascular accident, commonly known as a stroke) and Multiple Sclerosis (MS, a chronic autoimmune disease that affects the central nervous system, such as the brain and spinal cord).  During a review of Patient 6’s “CTI #4 for 5/5/2025 to 7/3/2025,” the CTI indicated a face-to-face encounter was signed by the MD on 5/2/2025, attesting/confirming, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.”e. During a review of Patient 7’s “Personal Information,” the record indicated Patient 7’s SOC was 8/15/2024, with a primary diagnosis of metabolic encephalopathy, Alzheimer’s dementia, and chronic (long-lasting) back and legs pain.  During a review of Patient 7’s “CTI #4 for 4/12/2025 to 6/10/2025,” the CTI indicated a face-to-face encounter was signed by the MD on 4/11/2025, attesting/confirming, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.”f. During a review of Patient 8’s “Personal Information,” the record indicated Patient 8’s SOC was 6/16/2024, with a primary diagnosis of metabolic encephalopathy and dementia.  During a review of Patient 8’s “CTI #5 (5th benefit period) for 4/12/2025 to 6/10/2025,” the CTI indicated a face-to-face encounter was signed by the MD on 4/11/2025, attesting/confirming, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.”g. During a review of Patient 9’s “Personal Information,” the record indicated Patient 9’s SOC was 4/4/2024, with a primary diagnosis of metabolic encephalopathy and type 2 diabetes mellitus (a chronic condition in which the body does not use insulin properly or does not produce enough insulin).  During a review of Patient 9’s “CTI #6 (6th benefit period) for 3/30/2025 to 5/28/2025,” the CTI indicated a face-to-face encounter was signed by the MD on 3/28/2025, attesting/confirming, “I attest/confirm that I composed this narrative based on my review of patient’s medical record, team assessment and/or examination of the patient.”During a review of the hospice agency’s policy and procedure (P&P) titled, “PHYSICIAN SERVICES-MEDICAL DIRECTOR,” revised April 2013, the P&P indicated, “The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the IDG, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms.The duties and responsibilities of the Medical Director will include, but not limited to the following…Providing written certification of the terminal illness including a short clinical narrative for all subsequent benefit periods and provide a face-to-face encounter visit with patient prior to third hospice benefit period and subsequent benefit periods…”

Upon patient record review, 1 of 3 (Patient #1) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Notification of the individual's (or representative's) right to receive an election statement addendum if there are conditions, items, services, and drugs the hospice has determined to be unrelated to the individual's terminal illness and related conditions and would not be covered by the hospice. • Information on the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), including the right to immediate advocacy and BFCC-QIO contact information Patient #1 election of benefit form did not have information on the BFCC-QIO.

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that if a patient revokes the election of hospice care or is discharged from hospice in accordance with §418.26, the hospice must forward to the patient's attending physician: Patient #2 revoked the election of hospice and had a discharge summary did not have evidence of : • A copy of the hospice discharge summary • The patient's clinical record, if requested

Upon patient record review, 1 of 5 (Patient #2) did not have evidence that the discharge summary includes all required information. Patient# 2 had a Discharge summary however it did not contain individualized information about the patient's treatments, symptoms, and information about pain management, the plan of care, latest physician orders.

Upon personnel record review, 1 of 4 (Personnel #2) did not have evidence that all Medical Social Services are provided by a qualified Medical Social Worker in accordance with the state's Social Work Practice Act, the hospice's policies and procedures and/or job descriptions. Personnel #2 discipline listed as MSW. No evidence of credential/ proof of degree for MSW. The only degree in personnel file is for "Doctor of Philosophy in Intercultural Studies". Verified with Administrator that there were no other degrees. Corrected on site.

Upon personnel record review, 1 of 4 (Personnel #1) did not have evidence the hospice obtained a criminal background check on all contracted individuals who have direct patient care and access to patient records. Personnel #1 Contracted SLP, per Omni therapy Inc, did not have a criminal background check, Office of Inspector General exclusion list check and national sex offender registry check.

Upon observation, there was no evidence the The Emergency Preparedness plan addresses patient population, including, but not limited to: • The type of services the hospice has • The ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans The agency has a roof leak that occurs when it rains. Paper Clinical Records and some HR records (MD's, PT/OT/ST, SW) are kept off-site. The agency, has no record that the emergency plan for continuity of operations and succession plans were initiated. Administrator, stated she did not consider this a reason to initiate plan.

Upon observation, there was no evidence the Emergency Plan communication plan must includes a primary only (not alternate) means for communicating with hospice's employees and Federal, state, tribal, regional, and local emergency management agencies.

Upon patient record review, 14 of 14 (Patients #1,2,3,4,5,6,7,8,9,10,11,11,13,14) did not have evidence that the patient chooses a health care provider, including an attending physician. Patients #1,2,3,4,5,6,7,8,9,10,11,11,13,14: The patient record did not have any indication of health care provider or attending physician choice.

Condition of Participation: Initial and Comprehensive Assessment of the Patient.

Upon patient record review, 9 of 14 (Patients #1,2,3,4,5,6,9,10,11) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: Acetaminophen 650mg PRN and Lidocaine 4% topical patch were included on hospice medication profile. However, these meds were not listed on ALF medication profile. The record indicated patient had Oxygen. Oxygen was not listed on either med profile Patient #2: Paroxetine was listed for depression on hospice medication profile and for insomnia on the ALF medication profile. Additionally, Vitamin C 500mg and Tylenol 500mg were included on hospice medication profile. However, these meds were not listed on ALF medication profile. The record indicated patient had Oxygen. Oxygen was not listed on either med profile Patient #3: Acetaminophen 650mg PRN, Melatonin 5mg, Lorazepam 2mg/1mL PRN, Atropine Sulfate 1% PRN, Bisacodyl 10mg PRN and Morphine Sulfate 0,25mL PRN, However, these meds were not listed on ALF medication profile. The record indicated patient had Oxygen. Oxygen was not listed on either med profile Patients #4, 5, 6, 9,10,11: These records indicated patients had Oxygen. Oxygen was not listed on the medication profile.

Upon patient record review, 13 of 14 (Patients #1,2,3,4,5,6,7,8,9,10,11,12,13) did not have evidence in the patient record that the comprehensive assessment includes a bereavement component which includes the needs of the patient's family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and is considered in the bereavement plan of care. Patients #1,2,3,4,5,6,7,8,9,10,11,12: There is no bereavement initial assessment in patient(s) record to date. Patient #13: The bereavement risk assessment was assessed. However, this assessment was not signed/dated by assigned staff.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon observation and patient record review, 14 of 14 (Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14), there was no evidence the hospice has an interdisciplinary group (IDG) or groups composed of individuals who work together to meet the physical, medical, psychosocial, emotional, and spiritual needs of the hospice patients and families facing terminal illness and bereavement. Interdisciplinary group members must provide the care and services offered by the hospice, and the group, in its entirety, must supervise the care and services. Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14: The EMR did not reflect MSW, SC or Medical Director/Attending Physician's signature of attendance/review at the IDG meetings. The routine IDG meetings reflected RN signature/date only. There is no evidence the IDG was composed of all disciplines to meet the physical, medical, psychosocial, emotional, and spiritual needs of the patient.

Upon patient record review, 9 of 14 (Patients #1,2,3,4,5,6,9,10,11) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. Patients #1,2,3,4,5,6,9,10,11: These records indicated patients had Oxygen. Oxygen was not listed on the plan of care medications.

Upon patient record review, 2 of 14 (Patient #2,3) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient #2: This patient had a hospital bed with rails, cane and front wheeled walker. These were not included on the Plan of Care. Patient #3: This patient had a hospital bed with rails. This was not included on the Plan of Care.

Upon patient record review, 2 of 14 (Patients #8,10) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #8: The POC listed Bereavement Coordinator (BC) Visit frequency of, 1 X per month (11/5/24). There are no visits to date in patient record that were made by the BC. Patient #10: The POC listed Bereavement Coordinator (BC) Visit frequency of, 1 X per month (6/16/24). There are no visits to date in patient record that were made by the BC.

Upon observation, there was no evidence the hospice ensures that non-core services for Speech Language Therapy (SLP) are provided to hospice patients and their families according to applicable laws and regulations. Agency has a contract for Speech-Language Pathology but per hospice the contracted service is having staffing issues and does not have a current SLP on staff to provide.

Upon patient record review, 5 of 14 (Patients #1,2,3,7,8) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #1: Aide visit notes from 2/3/25 to 3/13/25 are not signed/dated by the Aide. Patient #2: The POC listed Aide Visit frequency of, 2 X's per week (2/6/25). For first Benefit Week there was only one visit on 2/7/25. Patient #3: The POC listed Aide Visit frequency of, 2 X's per week (8/15/24). For first Benefit Week there was only one visit on 8/16/24. Patient #7: The POC listed Aide Visit frequency of, 2 X's per week (11/7/24). For first Benefit Week there were no visits. Patient #8: The POC listed Aide Visit frequency of, 2 X's per week (11/5/24). For first Benefit Week there was only one visit on 11/6/24.

Condition of Participation: Organization and Administration of Services.

Upon observation, there was no evidence the hospice is directed by a Board of Directors/governing body which assumes full legal authority and responsibility for the operation of the hospice. The hospice must ensure that all core and non-core services are provided to patients while maintaining a governing body that holds full legal responsibility for overseeing operations, including the Administrator and Alternate Administrator. The Administrator must designate an Alternate Administrator to ensure the continuous provision of hospice care services in their absence. The Alternate Administrator (Personnel #2) is named on a one page document located in her file that indicates in absence of Administrator she would serve in this role. There is no signed job description for this role. Additionally, the hospice must have an interdisciplinary group composed of all required disciplines to address the physical, medical , psychosocial, emotional and spiritual needs of each patient, ensuring a comprehensive and patient-centered approach to care. The hospice must ensure that all non-core services, including speech-language pathology are provided to hospice patients as needed to support their care plans.

Upon personnel record review, 1 of 13 (Personnel #4) did not have evidence the hospice employees and contract employees have received orientation on the hospice philosophy. Personal #4: The LVN does not have evidence of Hospice Philosophy training in the employee record.

Condition of Participation: Medical Director.

Upon patient record review, 8 of 14 (Patients #3,4,5,9,10,11,12,14) did not have evidence that the medical director or physician designee provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: • The primary terminal condition • Related diagnosis • Current subjective and objective medical findings • Current medication and treatment orders • Information about the medical management of any of the patient's conditions unrelated to the terminal illness Patients #3, 4, 5, 9, 10,11,12: The initial CTI's for benefit period 1 included physician narratives that are identical to the RN admission narrative note. Patient #14: In the electronic record (EMR), the CTI for recertification period 1 indicated "QQQ" in the physician narrative space provided on the form.

Upon patient record review, 3 of 14 (Patients #1,6,13) did not have evidence that before the recertification period for each patient, the medical director or physician designee must review the patient's clinical information and provide written documentation that it is anticipated that the patient's life expectancy is 6 months or less. Patient #1: In the electronic record (EMR), the CTI for recertification periods 2 & 3 indicated "QQQ" in the physician narrative space provided on the form. Patients #6, 13: The CTI for recertification period 2 included physician narrative that is identical to the RN admission narrative note.

Condition of Participation: Clinical Records.

Upon patient record review, 14 of 14 (Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14) did not have evidence that each patient record contains: • Signed election statement in accordance with 418.24 Patients #1,2,3,4,5,6,7,8,9,10,11,12,13,14: The Hospice Medicare Election statement does not provide BFCC-QIO contact information or Notice of Non Coved Items addendum information.

Upon patient record review, 8 of 14 (Patients #1,2,3,4,5,7,8,9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #1: The administrator signed on behalf of the MSW assigned/author of the initial assessment for psychosocial note. Patients #2,3,4,5,7,8,9: The MSW initial assessment notes not signed/dated.

Upon patient record review, 2 of 14 (Patients #11,12) did not have evidence that the discharge summary includes all required information. Patients #11,12: Discharge summary did not include required information as follows: • The patient's current plan of care • The patient's latest physician orders

Upon personnel record review, 8 of 13 (Personnel #2,3,4,8,9,11,12,13) did not have evidence of criminal background checks being obtained in accordance with state requirements. In the absence of state requirements, criminal background checks are obtained within three months of the date of employment for all states that the individual has lived or worked in the past 3 years. Personnel #2,3,4,8,9,11,12,13: Did not have criminal background checks in their files to date.

Observed in Leadership Session. Survey not completed

Observed in Leadership Session. The organization did not identify infection risks based on the following: - Its geographic location, community, and population served - The care, treatment, or services it provides - The analysis of its surveillance activities and other infection control data During the infection control session it was reported that the list of infectious diseases was not created or prioritized. The surveyor was unable to receive the document therefore could not be reviewed. Observed in Leadership Session. The organization did not identify infection risks based on the following: - Its geographic location, community, and population served - The care, treatment, or services it provides - The analysis of its surveillance activities and other infection control data During the infection control session it was reported that the list of infectious diseases was not created or prioritized. This was confirmed by the administrator. Observed in Leadership Session. The organization did not identify infection risks based on the following: - Its geographic location, community, and population served - The care, treatment, or services it provides - The analysis of its surveillance activities and other infection control data During the infection control session it was reported that the list of infectious diseases was not created or prioritized. This was confirmed by the administrator.

Observed in Leadership Session. The organization did not maintain confidential patient records in accordance with privacy and security standards of the Health Insurance Portability and Accountability Act (HIPAA) and other applicable state laws. During the leadership session it was noted that the DME, one pharmacy and lab contracts did not have business associate agreements. This was confirmed by the administrator.

Observed in Record Review. In 2 of 14 patient records reviewed, The hospice did not conduct and document a patient-specific comprehensive assessment and reassessment that identifies the patient’s need for hospice care and services. The assessment includes the patient’s need for physical, psychosocial, emotional, and spiritual care. During review of records 1,2 it was noted that assessments were not completed. For example in record 1, no assessment was documented and in record 2 no spiritual or bereavement assessment was documented. This was confirmed by the office manager.

Observed in Record Review. In 2 of 14 patient records reviewed, The hospice registered nurse did not complete the initial assessment of the patient within 48 hours of the of hospice care. During review of records 1,2 it was noted that there was no initial assessment documented several weeks after the election of hospice. This was confirmed by the office manager.

Observed in Record Review. In 2 of 14 patient records reviewed, The hospice’s interdisciplinary group, in consultation with the patient’s attending physician, did not complete the comprehensive assessment no later than five calendar days after the of hospice care. During review of records 1,2 it was noted that there was no initial assessment documented several weeks after the election of hospice. This was confirmed by the office manager.

Observed in Record Review. In 3 of 14 patient records reviewed, The organization did not assess the patient’s risk for falls. During review of records 5, 6, and 7 it was noted that a fall risk assessment had not been documented.

Observed in Record Review. In 2 of 14 patient records reviewed, The plan of care did not include an assessment of the patient’s needs and an identification of the provided services, including the management of discomfort and symptom relief. During review of records 3 and 5 it was noted that the patient had problems assessed that were not identified in the care plan. For example in record 3 the patient had a primary diagnosis of kidney failure but there were no interventions or goals in the POC related to kidney failure. This was confirmed by the office manager.

Observed in Individual Tracer. In 14 of 14 , The written plan of care was not based on the patient’s goals and the time frames, settings, and services required to meet those goals. During review of records 1-14, it was noted that the gols did not have appropriate time frames associated with them. Most goals had the end of the certification period as the target date. This was confirmed by the office manager.

Observed in Individual Tracer. In 1 of 14 patient records reviewed the surveor observed that the plan of care did not include all services needed for the palliation and management of the terminal illness and related conditions, including the following: - Interventions to manage pain and symptoms - A statement of the scope and frequency of the services necessary to meet the patient’s and family’s needs - Measurable outcomes anticipated from implementing and coordinating the plan of care - Medications and treatment necessary to meet the patient’s needs - Medical supplies and appliances necessary to meet the patient’s needs. During home visit 2, it was reported that there was no plan of care in place for the patient who had been admitted three weeks prior. This was confirmed by the Administrator.

Observed in Individual Tracer. The clinical record did not contain correct clinical information. During home visit 1 it was observed that the patient plan of care stated that the patient had an oxygen concentrator but no concentrator was in the patient's room. The concentrator had been removed due to the patient's improvement but the plan of care was not updated. This was confirmed by the Administrator.

Observed in Record Review. In 3 of 14 patient records reviewed, The organization provides the patient with care, treatment, or services according to the patient's individualized plan of care. During review of records 1, 2,3 visits were not provided. For example in record 1, nursing visits were ordered 1 time per week, social work 1 time per month and chaplain 1 time per month but no visits from these disciplines were documented. In record 2 no nursing visits were documented and in record 3 a social work note was found in the record but was empty. This was confirmed y the office manager.

Observed in Record Review. In 5 of 14 patient records reviewed, The organization did not inform the physician or other licensed practitioner when there is an unanticipated change in the patient’s condition or the patient is discharged or transferred. During review of records 4, 10, 11, 12, and 13 it was noted that there was no documentation of the physician being notified of the discharge. This was confirmed by the office manager.

Observed in Data Tracer. The organization did not use the results of data analysis to identify improvement opportunities. There were no PIPs conducted. This was confirmed by the administrator. Observed in Data Session. The organization did not analyze and compares internal data over time to identify levels of performance, patterns, trends, and variations. During the data systems session it was noted that there were no spread sheets or graphs being used to compare data over time. This was confirmed by the administrator.

Observed in Data Tracer. The organization did not evaluate actions to confirm that they resulted in improvements. No PIPs were conducted. This was confirmed by the administrator. Observed in Data Tracer. The organization did not act on improvement priorities. Needs for improvement were not prioritized and no PIPs were conducted. This was confirmed by the administrator. Observed in Data Tracer. The organization did not act when it does not achieve or sustain planned improvements. No PIPs were conducted. This was confirmed by the administrator.

Observed in Data Tracer. The organization did not act on improvement priorities. No priorities were set in the QAPI program and no PIPs were documented. This was confirmed by the administrator.

Observed in Data Tracer. The number and scope of annual performance improvement projects is based on the patients’ needs and internal organization needs. The projects reflect the scope, complexity, and past performance of the organization’s services and operations. No PIPs were being conducted. This was confirmed by the administrator.

Observed in Individual Tracer. In 2 of 3 home visits conducted, the organization did not use standard precautions, including the use of personal protective equipment, to reduce the risk of infection. During home visits1 and 3 it was observed that the clinicians did not use disposable paper towels to dry their hands per organizational policy. For example in home visit 1 the nurse used toilet tissue in the patient bathroom to dry her hands since she did not bring paper towels. This was confirmed by the Administrator.

Observed in Infection Control Tracer. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with the use of medical equipment, devices, and supplies. This was confirmed by the administrator. Observed in Infection Control Tracer. The organization's written infection prevention and control goals did not include the following: Limiting the spread of infections associated with procedures. This was confirmed by the administrator. Observed in Infection Control System Tracer. The organization's written infection prevention and control goals did not include the following: Addressing its prioritized risks. During the infection system tracer it was reported that infections were not prioritized. This was confirmed by the administrator.

Observed in Infection Control System Tracer. The organization did not educates staff about, at a minimum, the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza. This was confirmed by the administrator.

Observed in HR File Review. In 8 of 8 HR files reviewed, Staff competence was not assessed and documented once every three years, or more frequently as required by organization policy or in accordance with law and regulation. During review of HR files 1-8 competency records were not found with the exception of hand hygiene. This was confirmed by the office manager.

Observed in Record Review. In 6 of 14 patient records reviewed, The medical director, physician member of the interdisciplinary team, or physician designee reviews the clinical information for each hospice patient and did not provide written certification that the patient’s life expectancy is six months or less if the illness runs its normal course. Note: The determination of the patient’s life expectancy considers the following factors: - The primary terminal condition - Related diagnoses, if any - Current subjective and objective medical findings - Current medication and treatment orders - Information about the medical management of the patient’s conditions unrelated to the terminal condition During review of records 1,2, 8, 9, 10, and 11 it was noted that the certification of terminal illness did not contain a narrative. This was confirmed by the office manager.

Observed in Record Review. In 7 of 14 patient records reviewed, All entries in the patient record were not appropriately authenticated and dated in accordance with the organization’s policy and currently accepted standards of practice. During review of records 1,2,3 various clinical notes were not signed. For example in records 1,3, 5, 7, 9, 10, and 11 aide notes were not signed and in record 3, 7 of 9 nursing notes were not signed. In record 2 the spiritual assessment was not signed. This was confirmed by the office manager. Observed in Record Review. In 2 of 14 patient records reviewed, All entries in the patient record were not dated. During review of records 7 and 9 it was noted that clinician signatures were not dated. For example in record 7, nurses notes were not dated, although they were signed.

Observed in Record Review. In 5 of 14 patient records reviewed, When a patient is discharged or transferred, the organization did not give information about the care, treatment, or services provided to the patient to other service providers who will provide the patient with care, treatment, or services. During review of records 10, 11, 12, 13, and 14 there was no documentation of information being provided to the facility that would be caring for the patient after discharge. This was confirmed by the office manager.

Observed in Record Review. In 10 of 14 patient records reviewed, The organization did not provide a written summary to the patient’s physician or other licensed practitioner in accordance with law and regulation. During review of records 4, 5, 7, 8, 9, 10, 11, 12, 13 and 14 there was no documentation of the discharge summary being made available to or provided to the physician. This was confirmed by the office manager.

Observed in HR File Review. The organization did not obtain a criminal background check on the applicant as required by law and regulation or organization policy. During review of HR record 2 it was noted that a criminal background check had not been documented. This was confirmed by the office manager.