Every finding on record at The Crossroads Hospice, Inc.

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 Conditions of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) regarding Patient’s Rights were met as follows:  1. The HA failed to provide two of fourteen sampled patients (Patient 2 and Patient 11) information regarding their rights as a hospice patient in a language the patients understood.  This failure resulted in Patient 2 and Patient 11 not fully understanding or knowing their rights as a hospice patient. (Refer to L502).  2. The HA failed to inform six of fourteen sampled patients (Patient 2, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 11) about the services the HA provided and the limitations of these services.  This failure resulted in violations of Patient 2, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 11 rights to be fully informed about the purpose of the hospice care services and its specific limitations and were not able to make an informed decision (a choice made after carefully gathering and analyzing relevant information, considering potential outcomes, and understanding the associated risks and benefits) to accept or decline the hospice services. (Refer to L519). --- The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (decided and controlled by law) mandated compliance with Federal regulation for Patients' Rights to ensure their rights were not violated and receive the highest quality of hospice 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 provide two of fourteen sampled patients (Patient 2 and Patient 11) information regarding their rights as a hospice patient in a language the patients understood.  This failure resulted in Patient 2 and Patient 11 not fully understanding or knowing their rights as a hospice patient. --- Findings:  a. During a review of the hospice agency’s Patient Discharged Report (a list of patients who were discharged during a set period), dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated Patient 2 was admitted on 3/4/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease [relating to heart and blood vessels] that affects the arteries supplying blood to the heart muscle) with unspecified angina pectoris (chest pain caused by reduced blood flow to the heart muscle).  Patient 2 was discharged on 8/1/2024.   During a review of Patient 2’s Election of Hospice Medicare Benefit Informed Consent (a process in which patients are given important information, including possible risks and benefits, about a medical procedure or treatment), and Patient Treatment Authorization (a document signed by a patient which indicates that the patient agrees to palliative care, not curative treatment, and includes the Patient Rights and Patient Responsibilities), dated 3/4/2024, the information on the document was written in English.   During an interview on 7/9/2025 at 4:18 p.m., Patient 2 stated he speak and read in his native language and preferred documents to be written in the language he understands (his native language). Patient 2 stated a nurse from the hospice agency (unspecified) told him to sign documents written in English in the beginning of the hospice program.  Patient 2 stated that he was never informed he had a terminal disease (a disease that cannot be cured or treated and is expected to result in death).  Patient 2 stated that he never had a terminal disease and that the most severe thing he had was high blood pressure. Patient 2 stated from what he understood, hospice was a place for people who cannot take care of themselves, like a convalescent home (a facility that provides short-term, intensive rehabilitation and medical care for individuals recovering from surgery, illness, or injury).  Patient 2 stated he heard of the HA program though a website on the internet offering free fruits and vegetables. Patient 2 stated he clicked on the post, and someone (unable to specify who) called him, and Patient 2 gave them (unspecified hospice agency staff) his information.  Patient 2 stated he received vitamins, shampoo, protein shakes but never got free fruits and vegetables.  Patient 2 stated he received a statement in the mail from Medicare (a federal health insurance program for people age 65 or older) showing that the HA was charging him about $6,000 a month and the bill was too much for the services he was receiving. Patient 2 stated he informed the nurse that he did not want this hospice agency’s service, that it was illegal.   b. During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 11 was admitted to the HA on 6/5/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 11 was discharged on 5/30/2025.   During a telephone interview with Patient 11 on 7/11/2025 at 11:49 a.m. in his native language, Patient 11 stated he did not speak English. Patient 11 stated that he remembered signing some documents when the hospice nurse first came to see him. When Patient 11 was asked if he could share what documents he signed, Patient 11 stated, “I’m not a very smart man. I do not understand what the papers said, it was written in English. I signed them as the nurse told me to.”   During a review of Patient 11’s Election of Hospice Medicare Benefit Informed Consent, and Patient Treatment Authorization (that included the Patient Rights and Patient Responsibilities) was written in English and did not have a copy written in the native language Patient 11 understood.   During an interview on 7/14/2025 at 12:05 p.m., with the Director of Patient Care Services Designee (DPCSD) 2, DPCSD 2 stated that the patient consents should be in a language the patients understand. DPCSD  2 stated that the Patient Bill of Rights and Election of Benefits should be in the patients’ native language and that the HA should make sure that the nurse who visits the patient speaks the patient’s native language. The DPCSD stated it was important for the patient to feel comfortable and be communicated to in their native language because the patient cannot understand another language.    During an interview with DPCSD 2 on 7/14/2025 at 4:06 p.m., DPCSD 2 stated the Election of Hospice Medicare Benefit Informed Consent, and Patient Treatment Authorization has a version available written in Patient 2 and Patient 11’s native language. DPCSD 2 stated if the patient only spoke in his native language, then the forms used should have been in the patient’s native language.   During a review of the HA’s policy and procedure (P & P), titled “Patient Bill of Rights/Responsibilities,” revised May 2023, the P & P indicated the patient bill of rights/responsibilities would be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand.

Based on 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 inform six of fourteen sampled patients (Patient 2, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 11) about the scope of hospice services the HA provided and the limitations of these services. This failure resulted in violations of Patient 2, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 11 rights to be fully informed about the purpose of the hospice care services and its specific limitations and were not able to make an informed decision (a choice made after carefully gathering and analyzing relevant information, considering potential outcomes, and understanding the associated risks and benefits) to accept or decline the hospice services. --- Findings:a. During a review of the hospice agency’s Patient Discharged Report (a list of patients who were discharged during a set period), dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 2 was admitted on 3/4/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular [relating to the heart and blood vessels] disease that affects the arteries supplying blood to the heart muscle) with unspecified angina pectoris (chest pain caused by reduced blood flow to the heart muscle).  Patient 2 was discharged on 8/1/2024. During an interview on 7/9/2025 at 4:18 p.m., with Patient 2 in his native language, Patient 2 stated he was a patient of the HA but was no longer a part of the program.  Patient 2 stated he read in his native language and preferred documents to be in his native language.  Patient 2 stated a nurse from the HA (unspecified) told him to sign documents written in English in the beginning of the program. Patient 2 stated that he was never informed he had a terminal disease (a disease that cannot be cured or treated and is expected to result in death).  Patient 2 stated that he never had a terminal disease and that the most severe thing he had was high blood pressure. When asked if Patient 2 knew what hospice meant, Patient 2 stated hospice was a place for people who cannot take care of themselves, like a convalescent home (a facility that provides short-term, intensive rehabilitation and medical care for individuals recovering from surgery, illness, or injury).  Patient 2 stated he heard of the HA program though a website on the internet was offering free fruits and vegetables. Patient 2 stated he clicked on the post, and someone called him, and he gave them his information.  Patient 2 stated he received vitamins, shampoo, and protein shakes. Patient 2 stated he never got free fruits and vegetables.  Patient 2 stated he received a statement in the mail from Medicare (a federal health insurance program for people age 65 or older) showing that the HA was charging about $6,000 a month from him and it was too much for the services he was receiving. Patient 2 stated he informed the nurse that he did not want this hospice agency’s service, that it was illegal.  b. During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 5 was admitted on 6/6/2024 with a terminal diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure), with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). Patient 5 discharged on 7/13/2024.  Patient 5 was readmitted on 8/2/2024 with a terminal diagnosis of hypertensive heart disease with heart failure.  Patient 5 was discharged on 8/6/2024.    During an interview on 7/9/2025 at 2:39 p.m. with Family Member (FM) 1, FM 1 stated that she was Patient 5’s Power of Attorney.  FM 1 stated that she was not aware that Patient 5 signed up for hospice services with the HA on three separate occasions, on 2/16/2024, 6/6/2024 and 8/2/2024.  FM 1 stated that HA staff would come to Patient 5’s home to take her blood pressure, perform wound care, refill medications, bring toiletries like shampoo, and clean her bathroom. FM 1 stated that Patient 5 did not have a terminal disease.  FM 1 stated that she found out Patient 5 was in hospice when Patient 5’s physician called FM 1 and asked why Patient 5 was in hospice.  FM 1 stated Patient 5 has never had a terminal disease. FM 1 stated she had to cancel the services for Patient 5 because she was not informed that the hospice services Patient 5 was receiving would affect her Medicare insurance. c. During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 6 was admitted on 5/31/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 6 was discharged on 5/31/2025.   During an interview on 7/9/2025 at 11:21 a.m. with Patient 6, Patient 6 stated that she had hypertension (high blood pressure) that was controlled with medications and that she had chronic back pain. Patient 6 stated she was a patient of the hospice agency and that it was a program that provided services where a nurse visited every week to check her vital signs, provide toiletries, and provide medications when she was not feeling good. Patient 6 stated she did not have a heart condition, did not have chest pain, and did not have problems breathing.  Patient 6 stated she really did not know what hospice meant and that she did not have a terminal illness.  Patient 6 stated that hospice agency did not inform her that she had a terminal illness.  Patient 6 stated she left the program because they did not offer services to see a physician specialist to do mammograms (a specialized medical imaging to see inside the breast) and bone density (test that measures strength of bones).  d. During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 7 was admitted on 6/6/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 7 was discharged on 5/31/2025. During an interview on 7/9/2025 at 1:14 p.m., with Patient 7, Patient 7 stated that he did not have a terminal disease and that he was never informed by the HA that he had a terminal disease where he had a life expectancy of six months or less. During an interview on 7/9/2025 at 1:18 p.m., with Patient 8, Patient 8 stated she was Patient 7’s wife.  Patient 8 stated that Patient 7 had not had a sickness or illness where he was going to pass away since the Covid pandemic (Coronavirus disease 2019 is a contagious disease caused by the coronavirus SARS-CoV-2. In January 2020, the disease spread worldwide, resulting in the COVID-19 pandemic) in 2023.  Patient 8 stated that the HA did not tell her that the HA was taking care of patients with terminal diseases. Patient 8 stated that the HA services provided included a nurse that visited Patient 8 weekly to see how he was feeling, to check his temperature and blood pressure, and to check his feet for blisters because he was a diabetic (a chronic condition where the body either does not produce enough insulin or cannot effectively use the insulin it produces, leading to high blood sugar levels). Patient 8 stated that the HA did not inform them why Patient 7 was taken off hospice services. e. During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 8 was admitted on 6/6/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 8 was discharged on 5/31/2025. During an interview on 7/9/2025 at 1:30 p.m., with Patient 8, Patient 8 stated that she did not have a heart condition and that she did not have a terminal disease.  Patient 8 stated she just had a lot of problems with her right knee and needed a walker when she went grocery shopping.   Patient 8 stated the HA provided services that included a weekly visit from a nurse who would check her feet, blood pressure, temperature, oxygen and blood sugar. During an interview on 7/11/2025 at 1:43 p.m., with Patient 8, Patient 8 stated that she did not have heart disease and that her physician told her that her arteries were good and did not have any blockages. Patient 8 stated that she received a phone call on 7/11/2025 from Licensed Vocational Nurse (LVN) 1 that she was taken off hospice services. f. During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 11 was admitted to the HA on 6/5/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) with unspecified angina pectoris (chest pain caused by reduced blood flow to the heart muscle). Patient 11 was discharged on 5/30/2025. During a telephone interview with Patient 11 in his native language on 7/11/2025 at 11:49 a.m., Patient 11 stated that he had a primary care physician (PCP, health care providers that offer routine checkups, vaccines, and non-emergency medical care) that he saw regularly. Patient 11 stated that his PCP never informed him that he had a terminal illness or that he had a life expectancy of six months or less. Patient 11 stated he drove himself to the store and to his appointments. Patient 11 stated he did not need assistance with his daily activities. Patient 11 stated his PCP never referred him to hospice. Patient 11 stated that there was a lady who knocked on his apartment’s door and offered to enroll him to a program which will provide him with “bathroom things,” such as shampoo. Patient 11 stated the lady told him the program would also provide him with Glucerna (nutritional shakes for diabetic people), so that he would not need to buy milk from the store. Patient 11 stated the lady told him Glucerna was better than the store bought milk. When Patient 11 was asked what services were covered by the HA, Patient 11 stated the HA used to send a nurse to his apartment once a week to check his blood pressure, and the HA also sent him shampoo and Glucerna. Patient 11 stated he was not aware that hospice was a service for patients with terminal illness who had a life expectancy of six months or less. During an interview with Director of Patient Care Services (DPCSD) 2 on 7/14/2025 at 4:11 p.m., DPCSD 2 stated the registered nurse needed to explain about hospice services upon admission. DPCSD 2 stated if the patient was not alert and oriented, the explanation might have been given to a family member responsible for the patient. DPCSD 2 stated that hospice patients and/or their family members needed to understand the hospice was about comfort care and palliation (the provision of care and support to individuals with serious or life-limiting illnesses to improve their quality of life and relieve suffering) of symptoms.  During a review of the HA’s policy and procedure (P & P), titled “Admission Criteria and Process,” revised May 2023, the P & P indicated the patient must have a life-limiting illness with a life expectancy of six (6) months or less as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD. The patient must desire hospice services and be aware of the diagnosis and prognosis.

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 (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Initial and Comprehensive Assessment of the Patient was met as follows:  1. The HA failed to complete an initial assessment within 48 hours of hospice service election for eight of fourteen sampled patients (Patients 1, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12, Patient 13 and Patient 14). (Refer to L522).  As a result, Patient 1, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12, Patient 13, and Patient 14 did not have an initial assessment complete which increased the risk of a delay in the development of effective treatment and interventions to address patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. --- This systemic practice resulted in the failure of the hospice agency to deliver statutorily  mandated (a legal obligation established by a statute or law) compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the quality of care are provided to patients certified to receive hospice benefits.

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 initial comprehensive assessment (a thorough evaluation of a patient's physical, psychosocial, emotional, and spiritual needs related to patients terminal illness) was completed for eight of fourteen sampled  patients (Patients 1, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12, Patient 13 and Patient 14) by a registered nurse (RN) within 48 hours of electing hospice care. This failure resulted in Patient 1, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12, Patient 13, and Patient 14 did not have an initial assessment completed which increased the risk of a delay in the development of an effective treatment and interventions to addressed patient’s need for hospice care and services, and the patient’s need for physical, psychosocial, emotional, and spiritual care. --- Findings:a. During a review of the hospice agency’s Patient Discharged Report (a list of patients who were discharged during a set period), dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated Patient 1 was admitted on 9/26/2024 with a terminal diagnosis of congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). Patient 1 was discharged on 1/23/2025. During a review of Patient 1’s Nursing Clinical Note on the electronic health record, dated 4/10/2024, the Nursing Clinical Note dated 4/10/2025 was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height. During a concurrent interview and record review with Director of Patient Care Services Designee (DPCSD) 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note (initial comprehensive assessment) for Patient 1. DPCSD 2 stated there was no initial comprehensive assessment for Patient 1 done within 48 hours. DPCSD 2 stated the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) in generating a plan of care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for the patients. DPCSD 2 stated that without a comprehensive assessment the hospice agency would not be able to identify the patient’s needs and concerns or what interventions the patients needed. b. During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 5 was admitted on 6/6/2024  with a terminal diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure), with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). Patient 5 discharged on 7/13/2024.  Patient 5was readmitted on 8/2/2024 with a terminal diagnosis of hypertensive heart disease with heart failure.  Patient 5 was discharged on 8/6/2024.  During a review of Patient 5’s Nursing Clinical Note on the electronic health record, dated 6/6/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height. During a review of Patient 5’s Nursing Clinical Note on the electronic health record, dated 8/2/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height. During an interview on 7/9/2025 at 2:39 p.m. with Family Member (FM) 1, FM 1 stated that she was Patient 5’s Power of Attorney.  FM 1 stated that she was not aware that Patient 5 signed up for hospice services with the HA on three separate occasions, on 2/16/2024, 6/6/2024 and 8/2/2024.  FM 1 stated that HA staff would come to Patient 5’s home to take her blood pressure, perform wound care, refill medications, bring toiletries like shampoo, and clean her bathroom. FM 1 stated that Patient 5 did not have a terminal disease.  FM 1 stated that she found out Patient 5 was in hospice when Patient 5’s physician called FM 1 and asked why Patient 5 was in hospice.  FM 1 stated Patient 5 has never had a terminal disease. FM 1 stated she had to cancel the services for Patient 5 because she was not informed that the hospice services Patient 5 was receiving would affect her Medicare insurance. During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note (initial comprehensive assessment) dated 6/6/2024 and 8/2/2024 for Patient 5. DPCSD 2 stated the initial comprehensive assessment for Patient 5 was not completed within 48 hours. c. During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 6 was admitted on 5/31/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 6 was discharged on 5/31/2025. During a review of Patient 6’s Nursing Clinical Note on the electronic health record, dated 5/24/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height. During an interview on 7/9/2025 at 11:21 a.m. with Patient 6, Patient 6 stated that she had hypertension (high blood pressure) that was controlled with blood pressure medications and that she had chronic back pain. Patient 6 stated she was a patient of the hospice agency and that a nurse visited every week to check her vital signs, provide toiletries, and provide medications when she was not feeling good. Patient 6 stated she did not have a heart condition, did not have chest pain, and did not have problems breathing.  Patient 6 stated she did not know that hospice was for terminally ill, that she did not have a terminal illness and that her only problem was that she had chronic back pain.  Patient 6 stated that hospice agency did not inform her that she had a terminal illness.  Patient 6 stated she left the program because they did not offer services to see a physician specialist to do mammograms (a specialized medical imaging to see inside the breast) and bone density (test that measures strength of bones). During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note dated 5/24/2024 for Patient 6. DPCSD 2 stated there was no initial comprehensive assessment done for Patient 6 within 48 hours and that the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the IDG in generating a POC for the patients. d. During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 8 was admitted on 6/6/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 8 was discharged on 5/31/2025.  During a review of Patient 8’s Nursing Clinical Note on the electronic health record, dated 6/6/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height. During an interview on 7/9/2025 at 1:30 p.m., with Patient 8, Patient 8 stated that she did not have a heart condition and that she did not have a terminal disease.  Patient 8 stated she just had a lot of problems with her right knee and needed a walker when she went grocery shopping.During an interview on 7/11/2025 at 1:43 p.m., with Patient 8, Patient 8 stated that she did not have heart disease and that her physician told her that her arteries were good and did not have any blockages.  During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note (initial comprehensive assessment) dated 6/6/2024 for Patient 8. DPCSD 2 stated the initial comprehensive assessment for Patient 8 was not completed within 48 hours. DPCSD 2 stated the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the Interdisciplinary Group in generating a plan of care for the patients. DPCSD 2 stated that without a comprehensive assessment the hospice agency would not be able to identify the patient’s needs and concerns or what interventions the patients needed. e. During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 11 was admitted to the HA on 6/5/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 11 was discharged on 5/30/2025. During a review of Patient 11’s Nursing Clinical Note on the electronic health record, dated 6/5/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, medical record number, date of birth, age, gender, primary diagnosis, and height. During a telephone interview with Patient 11 on 7/11/2025 at 11:49 a.m., Patient 11 stated that he had a primary care physician (PCP, health care providers that offer routine checkups, vaccines, and non-emergency medical care) that he saw regularly. Patient 11 stated that his PCP never informed him that he had a terminal illness or that he had a life expectancy of six months or less. Patient 11 stated he drove himself to the store and to his appointments. Patient 11 stated he did not need assistance with his daily activities. Patient 11 stated his PCP never referred him to hospice. Patient 11 stated that there was a lady who knocked on his apartment’s door and offered to enroll him to a program which will provide him with “bathroom things,” such as shampoo. Patient 11 stated the lady told him the program would also provide him with Glucerna (a brand of meal replacement shakes and bars, specifically designed to help manage blood sugar levels), so that he would not need to buy milk from the store. Patient 11 stated the lady from HA (unspecified) told him Glucerna was better than the store-bought milk. During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note dated 6/5/2024 for Patient 11. DPCSD 2 stated there was no initial comprehensive assessment done for Patient 11 within 48 hours. DPCSD 2 stated the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the IDG in generating a POC for the patients. f. During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 12 was admitted to the HA on 8/5/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Patient 12 was discharged on 9/30/2024.  During a review of Patient 12’s Nursing Clinical Note on the electronic health record, dated 8/5/2024, the Nursing Clinical Note for 8/5/2024 was not completed. There was no assessment or information documented other than the patient’s name, medical record number, date of birth, age, gender, primary diagnosis, and height. During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note dated 8/5/2024 for Patient 12. DPCSD 2 stated there was no initial comprehensive assessment done for Patient 12 within 48 hours. DPCSD 2 stated the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the IDG in generating a POC for the patients. DPCSD 2 stated that without a comprehensive assessment the hospice agency would not be able to identify the patient’s needs and concerns or what interventions the patients needed. g. During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 13 was admitted to the HA on 11/14/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 13 was discharged on 7/10/2024.  During a review of Patient 13’s Nursing Clinical Note on the electronic health record, dated 11/14/2023, the Nursing Clinical Note for 11/14/2023 was not completed. There was no assessment for information documented other than the patient’s name, medical record number, date of birth, age, gender, primary diagnosis, and height. During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note for dated 11/14/2023 Patient 13. DPCSD 2 acknowledged there was no initial comprehensive assessment done for Patient 13 within 48 hours. DPCSD 2 stated the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the IDG in generating a POC for the patients. DPCSD 2 stated that without a comprehensive assessment the hospice agency would not be able to identify the patient’s needs and concerns or what interventions the patients needed. h. During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 14 was admitted to the HA on 3/12/2024 with a terminal diagnosis of heart disease (a broad term for conditions affecting the heart and blood vessels), unspecified. Patient 14 was discharged on 3/6/2025. During a review of Patient 14’s Nursing Clinical Note on the electronic health record, dated 3/12/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, medical record number, date of birth, age, gender, primary diagnosis, and height. During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note dated 3/12/2024 for Patient 14. DPCSD 2 acknowledged there was no initial comprehensive assessment done for Patient 14 within 48 hours. DPCSD 2 stated the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the IDG in generating a POC for the patients. DPCSD 2 stated that without a comprehensive assessment the hospice agency would not be able to identify the patient’s needs and concerns or what interventions the patients needed. During an interview with DPCSD 1 on 7/10/2025 at 2:50 p.m., DPCSD 1 stated the HA’s clinical records were “100% electronic.” DPCSD 1 stated the HA did not maintain paper charts for its patients. DPCSD 1 also stated the first Nursing Clinical Note in the Visit Notes section, which had the same date as the patient’s admission date, was the initial RN comprehensive assessment. During an interview with DPCSD 2 on 7/15/2025 at 11:38 am, DPCSD 2 stated that if an initial comprehensive assessment was not completed, it would be hard for that care plan to reflect the patient’s needs, that it would be impossible to determine if the care plan was an accurate reflection of that patient’s needs. DPCSD 2 stated that the patient’s immediate needs would be identified from the patient’s initial assessment and without initial assessment, the nurse would not be able to know how to take care of a patient.  DPCSD 2 stated that hospice patients had a high risk for hospitalization, and the purpose of the initial assessment was to identify the symptoms that needed palliation. During a review of the HA’s policy and procedure (P & P), titled “Initial Assessment,” revised May 2023, the P & P indicated that an initial assessment would be performed by an RN within 48 hours after the election of hospice care unless otherwise specified by the physician, patient, or representative to be completed in less than 48 hours.

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 (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services was met as follows: 1. The HA failed to include a detailed frequency of Skilled Nurse visit for pain and symptom management for six of fourteen sampled patients (Patient 2, Patient 5, Patient 6, Patient 7, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in Patient 2, Patient 5, Patient 6, Patient 7, Patient 11, Patient 12, Patient 13, and Patient 14 not to receive care and treatment to monitor and manage pain and the necessary services for the palliation (the provision of care and support to individuals with serious or life-limiting illnesses to improve their quality of life and relieve suffering)  and management of the terminal illness. (Refer to L547)  2. The HA failed to ensure the Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) met, reviewed, revised, and documented the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days for one of fourteen sampled patients (Patient 2). This failure of lack of coordination between the IDG could result in placing Patient 2 at increased risk for not meeting the hospice and care services needed to address Patient 2's physical, psychosocial, emotional, and spiritual needs. (Refer to L552). --- The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with the Federal Regulations for IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients.

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 include a detailed frequency of skilled nurse visit for pain and symptom management for six of fourteen sampled patients (Patient 2, Patient 5, Patient 6, Patient 7, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in Patient 2, Patient 5, Patient 6, Patient 7, Patient 11, Patient 12, Patient 13, and Patient 14 not to receive care and treatment to monitor and manage pain and the necessary services for the palliation (the provision of care and support to individuals with serious or life-limiting illnesses to improve their quality of life and relieve suffering)  and management of the terminal illness. --- Findings: During a review of the hospice agency’s Patient Discharged Report (a list of patients who were discharged during a set period), dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated the following: Patient 2 was admitted on 3/4/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular [relating to the heart and blood vessels] disease that affects the arteries supplying blood to the heart muscle) with unspecified angina pectoris (chest pain caused by reduced blood flow to the heart muscle). Patient 2 was discharged on 8/1/2024. Patient 5 was admitted on 6/6/2024 with a terminal diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure), with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). Patient 5 discharged on 7/13/2024.  Patient 5 was readmitted on 8/2/2024 with a terminal diagnosis of hypertensive heart disease with heart failure.  Patient 5 was discharged on 8/6/2024.   Patient 6 was admitted on 5/31/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 6 was discharged on 5/31/2025.  Patient 7 was admitted on 6/6/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 7 was discharged on 5/31/2025. Patient 11 was admitted on 6/5/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 11 was discharged on 5/30/2025. Patient 12 was admitted on 8/5/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Patient 12 was discharged on 9/30/2024.Patient 13 was admitted on 11/14/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 13 was discharged on 7/10/2024. Patient 14 was admitted on 3/12/2024 with a terminal diagnosis of heart disease (a broad term for conditions affecting the heart and blood vessels), unspecified. Patient 14 was discharged on 3/6/2025. a. During a review of Patient 2’s Initial Orders and Plan of Care for the certification period from 3/4/2024 through 6/1/2024 (certification #1), the Orders for Discipline and Treatments section indicated for the first week, the Skilled Nurse (SN, licensed nurse in general) visit frequency was one visit and two as needed visits for pain and symptom management. The SN visits for the following weeks was blank and did not indicate instructions when to visit the patient after the first week. During a review of Patient 2’s Certification of Plan of Care for the certification period from 6/02/2024 through 8/30/2024 (certification #2), the Orders for Discipline and Treatments section indicated for the first week, the Skilled Nurse (SN, licensed nurse in general) visit frequency was one visit and two as needed visits for pain and symptom management. The SN visits for the following weeks was blank and did not indicate instructions when to visit the patient after the first week.  b. During a review of Patient 5’s Initial Orders and Plan of Care for the certification period from 6/6/2024 to 9/3/2024 (certification #2), the Orders for Discipline and Treatments section indicated for the first week, the Skilled Nurse (SN, licensed nurse in general) visit frequency was one visit and two as needed visits for pain and symptom management. The SN visits for the following weeks were blank and did not indicate instructions for when to visit the patient after the first week.   During a review of Patient 5’s Initial Orders and Plan of Care for the certification period from 8/2/2024 to 9/20/2024 (certification #3), the Orders for Discipline and Treatments section indicated for the first week, the Skilled Nurse (SN, licensed nurse in general) visit frequency was one visit and two as needed visits for pain and symptom management. The SN visits for the following weeks were blank. c. During a review of Patient 6’s Initial Orders and Plan of Care for the certification period from 5/31/2024 through 8/28/2024 (certification #1), the Orders for Discipline and Treatments section indicated for the first week, the Skilled Nurse (SN, licensed nurse in general) visit frequency was one visit and two as needed visits for pain and symptom management. The SN visits for the following weeks was blank and did not indicate instructions when to visit the patient after the first week .    d. During a review of Patient 7’s Initial Orders and Plan of Care for the certification period from 6/6/2024 to 9/3/2024 (certification #1), the Orders for Discipline and Treatments section indicated for the first week, the Skilled Nurse (SN, licensed nurse in general) visit frequency was blank and the as needed visits for pain and symptom management was blank. The SN visits for the following weeks was blank and did not indicate instructions when to visit the patient after the first week.   c. During a review of Patient 11’s Initial Orders and Plan of Care, for the certification period of 6/5/2024 to 9/2/2024 (certification #1), the Orders for Discipline and Treatments section indicated the for the first week, the Skilled Nurse (SN, licensed nurse in general) visit frequency was one visit and two as needed visits for pain and symptom management. The SN visit frequency for the following weeks was blank and did not indicate instruction when to visit the patient after the first week. d. During a review of Patient 12’s Initial Orders and Plan of Care, for the certification period of 8/5/2024 to 11/2/2024 (certification #1), the Orders for Discipline and Treatments section indicated the for the first week, the SN visit frequency was one visit and two as needed visits for pain and symptom management. The SN visit frequency for the following weeks was blank and did not indicate instruction when to visit the patient after the first week. e. During a review of Patient 13’s Initial Orders and Plan of Care, for the certification period of 11/14/2023 to 2/11/2024 (certification #1), the Orders for Discipline and Treatments section indicated the for the first week, the SN visit frequency was one visit and two as needed visits for pain and symptom management. The SN visit frequency for the following weeks was blank and did not indicate instruction when to visit the patient after the first week. f.  During a review of Patient 14’s Initial Orders and Plan of Care, for the certification period of 3/12/2024 to 6/9/2024 (certification #1), the Orders for Discipline and Treatments section indicated the for the first week, the SN visit frequency was one visit and two as needed visits for pain and symptom management. The SN visit frequency for the following weeks was blank and did not indicate instruction when to visit the patient after the first week. During a concurrent interview and record review with Director of Patient Care Services (DPCSD) 2 on 7/14/2025 at 1:42 p.m., DPCSD 2 reviewed the Initial Orders and Plan of Care for Patient 2, Patient 6, Patient 11, Patient 12, Patient 13, and Patient 14. DPCSD 2 stated the plan of care must include a visit frequency for the entire certification period and not only the first week. DPCSD 2 stated the plan of care must include visit frequency for all disciplines involved in the patient’s care, such as nurses, social worker, chaplain, or physical therapist. DPCSD 2 stated the lack of visit frequency might have negative outcomes, such as pain and symptoms not monitored well if there was no set visit frequency. DPCSD 2 stated the visit frequency might be modified when the patient’s plan of care was updated. During a review of the HA’s policy and procedure (P & P), titled “The Plan of Care,” revised May 2023, the P & P indicated the written plan of care will contain Frequency/amount/duration and type of service.

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 interdisciplinary group Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) met, reviewed, revised, and documented the individualized plan of care as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days for one of fourteen sampled patients (Patient 2). This failure of lack of coordination between the IDG could result in placing Patient 2 at increased risk for not meeting the hospice and care services needed to address Patient 2’s physical, psychosocial, emotional, and spiritual needs. --- Findings: During a review of the hospice agency’s Patient Discharged Report (a list of patients who were discharged during a set period), dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated that Patient 2 was admitted on 3/4/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular [relating to heart and blood vessels] disease that affects the arteries supplying blood to the heart muscle) with unspecified angina pectoris (chest pain caused by reduced blood flow to the heart muscle).  Patient 2 was discharged on 8/1/2024. During a concurrent interview and record review, with the Director of Patient Care Services Designee (DPCSD) 2, on 7/14/2025 at 2:43 p.m., Patient 2’s IDG Plan of Care and Review of Comprehensive Assessment (a thorough evaluation of a patient's physical, psychosocial, emotional, and spiritual needs related to patients' terminal illness) on electronic health record dated 3/12/2024, 3/26/2024, 4/9/2024, 4/23/2024, 5/01/2024, 5/21/2024, 6/4/2024, 6/18/2024, 7/2/2024, 7/16/2024, and 7/30/2024 was reviewed. DPCSD 2 confirmed that the IDTs were not completed and signed by the registered nurse, social worker, physician, or spiritual care. DPCSD 2 stated that the IDG meetings should be held every 15 days and that the IDT meetings were important for the coordination of care in taking care of terminally ill patients. The DPCSD stated that during the IDG meeting, the patient’s plan of care and how the patient’s needs should be met were discussed. During a review of the facility’s policy and procedure (P&P) titled, “The Plan of Care” revised 5/2023, the P & P indicated that  the plan of care  will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care will be documented in the clinical record. On 7/14/2025, the Survey Team requested DPCSD 2 for P & P for Interdisciplinary Group meeting and the HA was unable to provide.

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 (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Organization and Administration of Services was met as follows: --- 1. The hospice agency failed to ensure the initial comprehensive assessment (a comprehensive evaluation conducted within 48 hours of a patient electing hospice care. It aims to identify the patient's immediate physical, psychosocial, and emotional needs related to patients' terminal illness, facilitating the development of a tailored care plan. This assessment is crucial for initiating appropriate care and support, ensuring comfort and dignity during the end-of-life journey) was completed for eight of 14 sampled patients (Patient 1, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12, Patient 13 and Patient 14) by a Registered Nurse within 48 hours of electing hospice care. (Refer to L651).As a result, Patient 1, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12, Patient 13, and Patient 14 did not have an initial assessment completed which increased the risk of a delay in the development of an effective care plan which could negatively impact patient well-being.2. The hospice agency failed to ensure seven of 14 sampled patients (Patient 1, Patient 2, Patient 5, Patient 9, Patient 12, Patient 13, and Patient 14) had the necessary Certification of Terminal Illness (CTI, a document completed by a physician to confirm a patient's eligibility for hospice care. It signifies that the patient's prognosis is that they have six months or less to live if the illness runs its normal course) completed by the medical director or a Medical Director Designee before receiving hospice services. (Refer to L651).As a result, Patient 1, Patient 2, Patient 5, Patient 9, Patient 12, Patient 13, and Patient 14 did not have a Certification of Terminal Illness completed which could have significant implications for billing and potential issues with Medicare reimbursement and fraud.3. The hospice agency failed to ensure the agency did not provide hospice services to four of 14 sampled patients (Patient 4, Patient 7, Patient 8 and Patient 13), who were outside of the agency’s approved Geographic Service Areas (GSA-which are the defined areas where the agency is licensed and authorized to operate). (Refer to L651).As a result, Patient 4, Patient 7, Patient 8 and Patient 13 were placed at increased risk for lack of timely access to care or follow-up.The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated (a legal obligation established by a statute or law) compliance with the federal regulations for Organization and Administration of Services to ensure provision of quality care and services to patients.

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 its governing body effectively managed services and quality assessment for 11 of 14 sampled patients (Patient 1, Patient 2, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 11, Patient 12, Patient 13, and Patient 14) as evidenced by:1.      Failing to ensure the initial comprehensive assessment (a comprehensive evaluation conducted within 48 hours of a patient electing hospice care. It aims to identify the patient's immediate physical, psychosocial, and emotional needs related to patients' terminal illness, facilitating the development of a tailored care plan. This assessment is crucial for initiating appropriate care and support, ensuring comfort and dignity during the end-of-life journey) was completed for Patient 1, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12, Patient 13, and Patient 14 by a registered nurse (RN) within 48 hours of electing hospice care.2.     Failing to ensure Patient 1, Patient 2, Patient 5, Patient 9, Patient 12, Patient 13, and Patient 14 had the necessary Certification of Terminal Illness (CTI, a document completed by a physician to confirm a patient's eligibility for hospice care. It signifies that the patient's prognosis is that they have six months or less to live if the illness runs its normal course) completed by the medical director or a Medical Director Designee before receiving hospice services. 3.     Failing to ensure the agency did not provide hospice services to Patient 4, Patient 7, Patient 8 and Patient 13, who were outside of the agency’s approved Geographic Service Areas (GSA) which are the defined areas where the agency is licensed and authorized to operate.These failures resulted in:1.     Patient 1, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12, Patient 13, and Patient 14 did not have an initial assessment completed which increased the risk of a delay in the development of an effective care plan which could negatively impact patient well-being.2.     Patient 1, Patient 2, Patient 5, Patient 9, Patient 12, Patient 13, and Patient 14 did not have a Certification of Terminal Illness completed which could have significant implications for billing and potential issues with Medicare reimbursement and fraud.3.     Patient 4, Patient 7, Patient 8 and Patient 13 were placed at increased risk for lack of timely access to care or follow-up.On 7/15/2025 at 2:41 p.m., the Department of Public Health 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) in the presence of the agency’s Owner and Director of Patient Care Services 2 related to the agency’s failure to ensure the governing body effectively managed services and quality assessment by failing to: 1. Ensure the initial comprehensive assessment was completed for Patients 1, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12, Patient 13, and Patient 14 by an RN within 48 hours of electing hospice care. 2. Ensure Patient 1, Patient 2, Patient 5, Patient 9, Patient 12, Patient 13, and Patient 14 had the necessary Certification of Terminal Illness completed by the medical director or a Medical Director Designee before receiving hospice services. 3. Ensure the agency did not provide hospice services to Patient 4, Patient 7, Patient 8 and Patient 13, who were outside of the agency’s approved Geographic Service Areas (GSA) which are the defined areas where the agency is licensed and authorized to operate.On 7/15/2025 at 4 p.m., the hospice agency was not able to submit an IJ removal plan (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 likely). The survey team completed the survey tasks and conducted an exit conference in the presence of the Owner, DPCSD 2, and Intake Coordinator, with the IJ not removed. --- Findings:During a review of the hospice agency’s Patient Discharged Report, dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated the following:Patient 1 was admitted on 9/26/2024 with a terminal diagnosis of congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). Patient 1 was discharged on 1/23/2025. Patient 2 was admitted on 3/4/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) with unspecified angina pectoris (chest pain caused by reduced blood flow to the heart muscle).  Patient 2 was discharged on 8/1/2024.Patient 4 was admitted on 5/26/2024 with a terminal disease of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris.  Patient 4 was discharged on 9/25/2024.Patient 5 was admitted on 6/6/2024 with a terminal diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure), with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). Patient 5 discharged on 7/13/2024.  Patient was readmitted on 8/2/2024 with a terminal diagnosis of hypertensive heart disease with heart failure.  Patient was discharged on 8/6/2024.  Patient 6 was admitted on 5/31/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 6 was discharged on 5/31/2025. Patient 7 was admitted on 6/6/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 7 was discharged on 5/31/2025.Patient 8 was admitted on 6/6/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 8 was discharged on 5/31/2025. Patient 9 was admitted to the HA on 10/31/2024 with a terminal diagnosis of atherosclerotic heart disease without angina pectoris. Patient 9 was discharged on 11/20/2024. Patient 11 was admitted to the HA on 6/5/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 11 was discharged on 5/30/2025.Patient 12 was admitted to the HA on 8/5/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Patient 12 was discharged on 9/30/2024. Patient 13 was admitted to the HA on 11/14/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 13 was discharged on 7/10/2024. Patient 14 was admitted to the HA on 3/12/2024 with a terminal diagnosis of heart disease (a broad term for conditions affecting the heart and blood vessels), unspecified. Patient 14 was discharged on 3/6/2025.1a. During a review of Patient 1’s Nursing Clinical Note on the electronic health record, dated 4/10/2025, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height.During a concurrent interview and record review with Director of Patient Care Services Designee (DPCSD) 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note (initial comprehensive assessment) dated 4/10/2025 for Patient 1. DPCSD 2 stated there was no initial comprehensive assessment for Patient 1 done within 48 hours. DPCSD 2 stated the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) in generating a plan of care (POC, a document detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for the patients. DPCSD 2 stated that without a comprehensive assessment the hospice agency would not be able to identify the patient’s needs and concerns or what interventions the patients needed.1b. During a review of Patient 5’s Nursing Clinical Note on the electronic health record, dated 6/6/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height. During a review of Patient 5’s Nursing Clinical Note on the electronic health record, dated 8/2/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height.During an interview on 7/9/2025 at 2:39 p.m. with Family Member (FM) 1, FM 1 stated that she was Patient 5’s Power of Attorney.  FM 1 stated that she was not aware that Patient 5 signed up for hospice services with the HA on three separate occasions, on 2/16/2024, 6/6/2024 and 8/2/2024.  FM 1 stated that HA staff would come to Patient 5’s home to take her blood pressure, perform wound care, refill medications, bring toiletries like shampoo, and clean her bathroom. FM 1 stated that Patient 5 did not have a terminal disease.  FM 1 stated that she found out Patient 5 was in hospice when Patient 5’s physician called FM 1 and asked why Patient 5 was in hospice.  FM 1 stated Patient 5 has never had a terminal disease. FM 1 stated she had to cancel the services for Patient 5 because she was not informed that the hospice services Patient 5 was receiving would affect her Medicare insurance.During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note (initial comprehensive assessment) dated 8/2/2025 for Patient 5. DPCSD 2 stated the initial comprehensive assessment for Patient 5 was not completed within 48 hours. 1c. During a review of Patient 6’s Nursing Clinical Note on the electronic health record, dated 5/31/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height.During an interview on 7/9/2025 at 11:21 a.m. with Patient 6, Patient 6 stated that she had hypertension (high blood pressure) that was controlled with blood pressure medications and that she had chronic back pain. Patient 6 stated she was a patient of the hospice agency and that a nurse visited every week to check her vital signs, provide toiletries, and provide medications when she was not feeling good. Patient 6 stated she did not have a heart condition, did not have chest pain, and did not have problems breathing.  Patient 6 stated she did not know that hospice was for terminally ill, that she did not have a terminal illness and that her only problem was that she had chronic back pain.  Patient 6 stated that hospice agency did not inform her that she had a terminal illness.  Patient 6 stated she left the program because they did not offer services to see a physician specialist to do mammograms (a specialized medical imaging to see inside the breast) and bone density (test that measures strength of bones).During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note  dated 5/31/2024 for Patient 6. DPCSD 2 stated there was no initial comprehensive assessment done for Patient 6 within 48 hours and that the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the IDG in generating a POC for the patients. 1d. During a review of Patient 8’s Nursing Clinical Note on the electronic health record, dated 6/6/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height.During an interview on 7/9/2025 at 1:30 p.m., with Patient 8, Patient 8 stated that she did not have a heart condition and that she did not have a terminal disease.  Patient 8 stated she just had a lot of problems with her right knee and needed a walker when she went grocery shopping.  During an interview on 7/11/2025 at 1:43 p.m., with Patient 8, Patient 8 stated that she did not have heart disease and that her physician told her that her arteries were good and did not have any blockages.  During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note (initial comprehensive assessment) dated 6/6/2024 for Patient 8. DPCSD 2 stated the initial comprehensive assessment for Patient 8 was not completed within 48 hours. DPCSD 2 stated the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the Interdisciplinary Group in generating a plan of care for the patients. DPCSD 2 stated that without a comprehensive assessment the hospice agency would not be able to identify the patient’s needs and concerns or what interventions the patients needed.1e. During a review of Patient 11’s Nursing Clinical Note on the electronic health record, dated 6/5/2024, the Nursing Clinical Note for 6/5/2024 was not completed. There was no assessment or information documented other than the patient’s name, medical record number, date of birth, age, gender, primary diagnosis, and height. During a telephone interview with Patient 11 on 7/11/2025 at 11:49 a.m., Patient 11 stated that he had a primary care physician (PCP, health care providers that offer routine checkups, vaccines, and non-emergency medical care) that he saw regularly. Patient 11 stated that his PCP never informed him that he had a terminal illness or that he had a life expectancy of six months or less. Patient 11 stated he drove himself to the store and to his appointments. Patient 11 stated he did not need assistance with his daily activities. Patient 11 stated his PCP never referred him to hospice. Patient 11 stated that there was a lady who knocked on his apartment’s door and offered to enroll him to a program which will provide him with “bathroom things,” such as shampoo. Patient 11 stated the lady told him the program would also provide him with Glucerna (a brand of meal replacement shakes and bars, specifically designed to help manage blood sugar levels), so that he would not need to buy milk from the store. Patient 11 stated the lady from HA (unspecified) told him Glucerna was better than the store-bought milk.During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note dated 6/5/2024 for Patient 11. DPCSD 2 stated there was no initial comprehensive assessment done for Patient 11 within 48 hours. DPCSD 2 stated the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the IDG in generating a POC for the patients. 1f. During a review of Patient 12’s Nursing Clinical Note on the electronic health record, dated 8/5/2024, the Nursing Clinical Note for 8/5/2024 was not completed. There was no assessment or information documented other than the patient’s name, medical record number, date of birth, age, gender, primary diagnosis, and height. During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note dated 8/5/2024 for Patient 12. DPCSD 2 stated there was no initial comprehensive assessment done for Patient 12 within 48 hours. DPCSD 2 stated the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the IDG in generating a POC for the patients. DPCSD 2 stated that without a comprehensive assessment the hospice agency would not be able to identify the patient’s needs and concerns or what interventions the patients needed.1g. During a review of Patient 13’s Nursing Clinical Note on the electronic health record, dated 11/14/2023, the Nursing Clinical Note for 11/14/2023 was not completed. There was no assessment for information documented other than the patient’s name, medical record number, date of birth, age, gender, primary diagnosis, and height. During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note dated 11/14/2023 for Patient 13. DPCSD 2 acknowledged there was no initial comprehensive assessment done for Patient 13 within 48 hours. DPCSD 2 stated the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the IDG in generating a POC for the patients. DPCSD 2 stated that without a comprehensive assessment the hospice agency would not be able to identify the patient’s needs and concerns or what interventions the patients needed.1h. During a review of Patient 14’s Nursing Clinical Note on the electronic health record, dated 3/12/2024, the Nursing Clinical Note for 3/12/2025 was not completed. There was no assessment or information documented other than the patient’s name, medical record number, date of birth, age, gender, primary diagnosis, and height.During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 11:12 a.m., DPCSD 2 reviewed the Nursing Clinical Note dated 3/12/2024 for Patient 14. DPCSD 2 acknowledged there was no initial comprehensive assessment done for Patient 14 within 48 hours. DPCSD 2 stated the initial comprehensive assessment needed to be completed within 48 hours upon admission because it would guide the IDG in generating a POC for the patients. DPCSD 2 stated that without a comprehensive assessment the hospice agency would not be able to identify the patient’s needs and concerns or what interventions the patients needed.During an interview with DPCSD 1 on 7/10/2025 at 2:50 p.m., DPCSD 1 stated the HA’s clinical records were “100% electronic.” DPCSD 1 stated the HA did not maintain paper charts for its patients. DPCSD 1 also stated the first Nursing Clinical Note in the Visit Notes section, which had the same date as the patient’s admission date, was the initial RN comprehensive assessment. During an interview with DPCSD 2 on 7/15/2025 at 11:38 am, DPCSD 2 stated that if an initial comprehensive assessment was not completed, it would be hard for that care plan to reflect the patient’s needs, that it would be impossible to determine if the care plan was an accurate reflection of that patient’s needs. DPCSD 2 stated that the patient’s immediate needs would be identified from the patient’s initial assessment and without initial assessment, the nurse would not be able to know how to take care of a patient.  DPCSD 2 stated that hospice patients had a high risk for hospitalization, and the purpose of the initial assessment was to identify the symptoms that needed palliation.During a review of the HA’s policy and procedure (P & P), titled “Initial Assessment,” revised May 2023, the P & P indicated that an initial assessment would be performed by an RN within 48 hours after the election of hospice care unless otherwise specified by the physician, patient, or representative to be completed in less than 48 hours. During a review of the HA’s P & P, titled “Comprehensive Assessment,” revised May 2023, the P & P indicated that a comprehensive patient assessment would be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician.The P & P indicated the comprehensive patient assessment should include at least the following information:-         An assessment of pain, including the origin, location, duration, severity, and relief measures.-         An assessment of severity of secondary symptoms, such as nausea, vomiting, respiratory distress, and nutritional status.-         Nature and condition causing admission.-         Alleviating and exacerbating factors for physical symptoms.-         Current treatment and patient response to that treatment.-         A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data relate to pertinent physical findings and the patient's terminal illness.-         Patient’s functional status includes, but not limited to, the degree of self-care and the amount of level of assistance needed. During a review of the HA’s P & P, titled “The Plan of Care,” revised May 2023, the P & P indicated the plan of care would be based on the initial, comprehensive, and ongoing assessments performed by members of the interdisciplinary group…” 2a. During a review of Patient 1’s Certification of Terminal Illness for the for certification period from 6/27/2024 through 9/24/2024 (2nd certification), the CTI was not signed by the hospice physician.During a review of Patient 1’s Certification of Terminal Illness for the certification period from 9/26/2024 through 11/24/2024 (3rd certification), the CTI was not signed by the hospice physician.During a review of Patient 1’s Certification of Terminal Illness for the certification period from 11/25/2024 through 1/23/2025 (4th certification), the CTI was not signed by the hospice physician.A phone call to interview Patient 1 was made on 7/9/2025 at 12:57 p.m. The surveyor was not able to leave a voicemail as the patient’s phone number had been changed, disconnected or no longer in service. The HA was not able to provide an alternate number.2b. During a review of Patient 2’s Certification of Terminal Illness for the certification period from 3/4/2024 through 6/1/2024 (1st certification), the CTI was not signed by the hospice physician.During a review of Patient 2’s Certification of Terminal Illness for the certification period from 6/2/2024 through 8/30/2024 (2nd certification), the CTI was not signed by the hospice physician.During an interview on 7/9/2025 at 4:18 p.m., Patient 2 stated he was a patient of the HA but was no longer a part of the program.  Patient 2 stated that he was never informed he had a terminal disease.  Patient 2 stated that he never had a terminal disease and that the most severe thing he had was high blood pressure. When asked if Patient 2 knew what hospice meant, Patient 2 stated hospice was a place for people who cannot take care of themselves, like a convalescent home.  Patient 2 stated he heard of the HA program though an internet post that was offering free fruits and vegetables. Patient 2 stated he clicked on the post, and "someone called me", and he gave them his information.  Patient 2 stated he received vitamins, shampoo, and protein shakes and never got free fruits and vegetables.  Patient 2 stated he received a statement in the mail from Medicare showing that the HA was charging "About $6,000 a month from me and it was too much for the services I was receiving". Patient 2 stated he informed the nurse that he did not want this service, that it was illegal.2c. During a review of Patient 5’s Certification of Terminal Illness for the certification period from 2/16/2024 through 5/15/2025 (1st certification), the CTI was not signed by the hospice physician.During a review of Patient 5’s Certification of Terminal Illness for the certification period from 6/6/2024 through 9/3/2024 (2nd certification), the CTI was not signed by the hospice physician.During a review of Patient 5’s Certification of Terminal Illness for the certification period from 8/2/2024 through 9/30/2024 (3rd certification), the CTI was not signed by the hospice physician.During an interview on 7/9/2025 at 2:39 p.m. with Family Member (FM) 1, FM 1 stated that she was Patient 5’s Power of Attorney.  FM 1 stated that she was not aware that Patient 5 signed up for hospice services with the HA on three separate occasions.  FM 1 stated that people would come to Patient 5’s home to do wound care, refill medications, bring toiletries like shampoo, and clean her bathroom.  FM 1 stated that Patient 5 had not been diagnosed with a terminal disease and that she was later notified that Patient 5 was in hospice when Patient 5’s physician called her asking why Patient 5 was in hospice.  FM 1 stated she had to cancel the services for Patient 5 because she was not informed that the services Patient 5 was receiving would affect her Medicare insurance. During a concurrent interview and record review with DPCSD 2 on 7/14/2025, at 11:47 a.m., DPCSD 2 reviewed the CTI for Patient 5 for the certification period from 2/16/2024 through 5/15/2025 (certification #1), 6/6/2024 through 9/3/2024 (certification #2) and from 8/2/2024 through 9/30/2024 (certification #3). DPCSD 2 confirmed that the CTI was not signed and dated by the Medical Director or Medical Director Designee. DPCSD 2 stated the CTIs could only be signed and dated by HA’s physician or a physician designee to be considered completed. 2d. During a review of Patient 9’s CTI for the certification period of 10/31/2024 to 1/28/2024 (certification #1), the CTI was not signed by the hospice physician. 2e. During a review of Patient 12’s CTI for the certification period of 10/31/2024 to 1/28/2024 (certification #1), the CTI was not signed by the hospice physician.2f. During a review of Patient 13’s CTI for the certification period of 11/14/2023 to 2/11/2024 (certification #1), the CTI was not signed by the hospice physician.During a review of Patient 13’s CTI for the certification period of 2/12/2024 to 5/11/2025 (certification #2), the CTI was not signed by the hospice physician.2g. During a review of Patient 14’s CTI for the certification period of 3/12/2024 to 6/9/2024 (certification #1), the CTI was not signed by the hospice physician.During a review of Patient 14’s CTI for the certification period of 6/10/2024 to 9/7/2024 (certification #2), the CTI was not signed by the hospice physician.During a review of Patient 14’s CTI for the certification period of 11/7/2024 to 1/5/2025 (certification #4), the CTI was not signed by the hospice physician.During a review of Patient 14’s CTI for the certification period of 1/6/2025 to 3/6/2025 (certification #5), the CTI was not signed by the hospice physician. During an interview with Director of Patient Care Services 2 (DPCSD 2) on 7/14/2025 at 10:39 a.m., DPCSD 2 stated all admissions began with a referral. DPCSD 2 stated after the HA received a referral from a primary care physician (PCP, health care providers that offer routine checkups, vaccines, and non-emergency medical care), skilled nursing facility (a medical setting that provides 24-hour skilled nursing care and rehabilitation services, primarily for individuals who no longer require the intensive care of a hospital but still need professional medical support and assistance with daily living activities), or a hospital, the HA would request for the medical records of the potential patient being referred. The DPCS or DPCSD would then review the medical records with the hospice’s Medical Director to determine appropriateness for hospice. If the potential patient was determined to be appropriate for hospice, an RN would visit and assess the potential patient. The RN would report the assessment findings to the MD, and if the MD decided the potential patient was appropriate for hospice, the MD would give a verbal certification to the RN. DPCSD 2 stated the MD would still have to sign and date the CTI. During a concurrent interview and record review with DPCSD 2 on 7/14/2025, at 11:47 a.m., DPCSD 2 reviewed the CTIs for Patient 1, Patient 2, Patient 5, Patient 9, Patient 12, Patient 13, and Patient 14. DPCSD 2 confirmed that the CTIs were not signed and dated by the Medical Director or Medical Director Designee. DPCSD 2 stated the CTIs could only be signed and dated by HA’s physician or a physician designee to be considered completed. DPCSD 2 stated there was no records that support Patient 1, Patient 2, Patient 5, Patient 9, Patient 12, Patient 13, and Patient 14 that would support patients terminal diagnoses and unable to provide evidence patients diagnoses of terminal illness. During an interview on 7/14/2025 at 11:47 a.m., DPCSD 2 stated that CTI was needed for every certification period. DPSCD 2 stated that in addition to CTI, a face-to-face encounter with a physician or physician designee would be required before the start of the third certification period. During a telephone interview with the HA’s Medical Director (MD) on 7/14/2025 at 12:24 p.m., the MD stated the CTI had to be completed and signed by the hospice agency’s MD before the patient started receiving hospice services to ensure the patient was appropriate for hospice. The MD stated a CTI also needed to be completed and signed by the certifying physician each time the patient was recertified to make sure that patient was still appropriate for hospice. The MD reiterated DPCSD 2’s statement regarding the admission process.During an interview with DPCSD 2 on 7/14/2025 at 2:05 p.m., DPCSD 2 stated he was not part of the organization at that time and could not speak on how the HA certified the patients without complete CTIs.During an interview with DPCSD 2 on 7/15/2025 at 11:47 a.m., DPCSD 2 stated, “If there were no CTI, the hospice agency would not know how to provide care for the patient. Not having a CTI is like not having consent to perform care. I do not know how they billed for patients without a CTI.”During an interview with DPCSD 2 on 7/15/2025 at 2:05 p.m., when DPCSD 2 was asked if the patients without completed CTIs could have been billed for services that were not appropriate for them, DPCSD 2 stated he could not answer since he was not part of the organization at that time.During a review of the HA’s policy and procedure (P&P) titled “Certificate of Terminal Illness,” dated 5/2023, the P&P indicated that both the attending physician’s and Medical Director’s signed and dated initial certification forms must be on file prior to billing the first claim. The P&P indicated that a subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director.  At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patient’s medical record or, if applicable, examination of the patient.  3a. During a review Patient 4’s Patient Basic Info, the Patient Basic Info indicated Patient 4 lived in Cutler, California.  During a review of Mapquest (an online web mapping service) driving directions, the Mapquest indicated Cutler is a city located in Tulare County and is approximately 200 miles north of Los Angeles.  The HA is located in Los Angeles County.3b. During a review of Patient 7’s Patient Basic Info, the Patient Basic Info indicated that Patient 7 lived in Lemoore, California.During a review of Mapquest driving directions, Lemoore is a city located in Kings County, California.  It is approximately 200 miles north of Los Angeles.  The HA is located in Los Angeles County.During an interview on 7/11/2025 at 1:43 p.m., Patient 8 stated that Patient 7 was her husband and that she and Patient 7 lived in Lemoore which was in Kings County.3c. During a review of Patient 8’s Patient Basic Info, the Patient Basic Info indicated Patient 7 lived in Lemoore, California. During a review of Mapquest  driving directions, Lemoore is a city located in Kings County, California.  It is approximately 200 miles north of Los Angeles.  The HA is located in Los Angeles County. During an interview on 7/11/2025 at 1:43 p.m., Patient 8 stated that Patient 7 was her husband and that she and Patient 7 lived in Lemoore which was in Kings County.3d. During a review of Patient 13’s Patient Basic Info for Patient 13, the Patient Basic Info indicated he lived in Fresno, California. During a review of Mapquest driving directions, Fresno is a city located in Fresno County, California and is approximately 220 miles north of Los Angeles.  The HA is located in Los Angeles County.  During a concurrent interview and record review with DPCSD 2 on 7/14/2025 at 1:38 p.m., DPCSD 2 reviewed the letter for initial licensure survey by the accrediting organization, dated 6/4/2021. DPCSD 2 stated the letter indicated the approved Geographic Service Areas (GSAs, the specific region where a business, organization, or service provider is authorized to offer its services. GSA is often established by local, state, or federal laws, within which a company can legally operate and deliver its offerings) were as follows: Los Angeles County, Orange County, Ventura County, Riverside County, and San Bernadino County.  DPCSD  2 stated that Patient 4, Patient 7, Patient 8, and Patient 13 did not live in the approved GSA and that all patients admitted to the hospice agency should live within the approved GSA. The DPCSD 2 stated that it was important to provide care to patients within the GSA to ensure that those were areas that we could take care of the patient and ensure we had appropriate staffing to take care of the patient.On 7/15/2025 at 1 p.m., DPCSD 2 was not able to provide the approved GSA for Kings County, Tulare County, and Fresno County as requested by the survey team. During a review of the HA’s policy and procedure (P & P), titled “Admission Criteria and Process,” revised May 2023, the P & P indicated the patient must reside within the geographical area that the hospice agency services.During a review of the HA’s P & P titled “Governing Body,” revised May 2023, the P & P indicated the governing body would assume full legal authority, responsibility, decision-making, and accountability for the overall management and operations, human resource management, review of the organization’s budget and operational plans, and its quality assessment and performance improvement (QAPI) program.

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 (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Clinical Records was met as follows: 1. The HA failed to ensure the patient’s clinical records included the initial comprehensive assessment of eight of fourteen sampled patients (Patients 1, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12, Patient 13, and Patient 14). As a result, Patient 1, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12, Patient 13, and Patient 14 did not have complete clinical records that could potentially not identify the patients’ current health conditions and affect the care and services they received that could lead to hospitalization and death. (Refer to L672). 2. The HA failed to ensure that seven of fourteen sampled patients (Patient 1, Patient 2, Patient 5, Patient 9, Patient 12, Patient 13, and Patient 1 had the necessary Certification of Terminal Illness (CTI, a document completed by a physician to confirm patients’ eligibility for hospice care. It signifies that the patient’s prognosis is that they have six months or less to live if the illness runs its normal course) completed as part of their medical records. (Refer to L676). As a result, Patient 1, Patient 5, Patient 9, Patient 12, Patient 13, and Patient 14 were placed at risk for receiving care and/or billing that was not appropriate for their health condition. --- The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (legal obligation established by a statute or law) compliance with the federal regulations for  Clinical Records to ensure provision of quality care and services to patients.

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 that eight of fourteen sampled patient’s Patients 1, Patient 5, Patient 6, Patient 8, Patient 11, Patient 12, Patient 13, and Patient 14) clinical records included the initial comprehensive assessment. This failure resulted in Patient 1, Patient 5, Patient 6, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 not having complete clinical records that could potentially not identify the patients’ current health conditions and affect the care and services they received that could lead to hospitalization and death. --- Findings: During a review of the hospice agency’s Patient Discharged Report (a list of patients who were discharged during a set period), dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated the following: Patient 1 was admitted on 9/26/2024 with a terminal diagnosis of congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). Patient 1 was discharged on 1/23/2025.   Patient 5 was admitted on 6/6/2024 with a terminal diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure), with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). Patient 5 discharged on 7/13/2024.  Patient 5 was readmitted on 8/2/2024 with a terminal diagnosis of hypertensive heart disease with heart failure.  Patient 5 was discharged on 8/6/2024.   Patient 6 was admitted on 5/31/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 6 was discharged on 5/31/2025.   Patient 8 was admitted on 6/6/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 8 was discharged on 5/31/2025.   Patient 11 was admitted on 6/5/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 11 was discharged on 5/30/2025. Patient 12 was admitted on 8/5/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Patient 12 was discharged on 9/30/2024. Patient 13 was admitted on 11/14/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 13 was discharged on 7/10/2024. Patient 14 was admitted on 3/12/2024 with a terminal diagnosis of heart disease (a broad term for conditions affecting the heart and blood vessels), unspecified. Patient 14 was discharged on 3/6/2025. a. During a review of Patient 1’s Nursing Clinical Note on the electronic health record, dated 4/10/2025, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height. b. During a review of Patient 5’s Nursing Clinical Note on the electronic health record, dated 6/6/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height. During a review of Patient 5’s Nursing Clinical Note on the electronic health record, dated 8/2/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height. c. During a review of Patient 6’s Nursing Clinical Note on the electronic health record dated, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height.  d. During a review of Patient 8’s Nursing Clinical Note on the electronic health record, dated 6/6/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, date of birth, age, gender, primary diagnosis and height. e. During a review of Patient 11’s Nursing Clinical Note on the electronic health record, dated 6/5/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, medical record number, date of birth, age, gender, primary diagnosis, and height. f. During a review of Patient 12’s Nursing Clinical Note on the electronic health record, dated 8/5/2024, the Nursing Clinical Note for 8/5/2024 was not completed. There was no assessment or information documented other than the patient’s name, medical record number, date of birth, age, gender, primary diagnosis, and height.g. During a review of Patient 13’s Nursing Clinical Note on the electronic health record dated 11/14/2023, the Nursing Clinical Note for 11/14/2023 was not completed. There was no assessment for information documented other than the patient’s name, medical record number, date of birth, age, gender, primary diagnosis, and height. h. During a review of Patient 14’s Nursing Clinical Note on the electronic health record, dated 3/12/2024, the Nursing Clinical Note was not completed. There was no assessment or information documented other than the patient’s name, medical record number, date of birth, age, gender, primary diagnosis, and height. During an interview with Director of Patient Care Services Designee (DPCSD) 2 on 7/15/2025 at 11:38 am, DPCSD 2 stated that if an initial comprehensive assessment was not completed, it would be hard for that care plan to reflect the patient’s needs, that it would be impossible to determine if the care plan was an accurate reflection of that patient’s needs. DPCSD 2 stated that the patient’s immediate needs would be identified from the patient’s initial assessment and without initial assessment, the nurse would not be able to know how to take care of a patient.  DPCSD 2 stated that hospice patients had a high risk for hospitalization, and the purpose of the initial assessment was to identify the symptoms that needed palliation. During an interview with DPCSD 2 on 7/15/2025 at 12:15 p.m., DPCSD 2 stated the lack of complete and accurate clinical records could affect the patient negatively, such as the physician and other health professionals involved were not aware of the patient’s current health status.  During a review of the HA’s policy and procedure (P & P), titled “Initial Assessment,” revised May 2023, the P & P indicated that an initial assessment would be performed by an RN within 48 hours after the election of hospice care unless otherwise specified by the physician, patient, or representative to be completed in less than 48 hours. The P & P indicated that the initial assessment will be filed in the patient's clinical record.

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 that seven of fourteen sampled patient’s (Patient 1, Patient 2, Patient 5, Patient 9, Patient 12, Patient 13, and Patient 14) clinical records included the Certification of Terminal Illness (CTI, a document completed by a physician to confirm a patients eligibility for hospice care. It signifies that the patient’s prognosis is that they have six months or less to live if the illness runs its normal course) completed as part of their medical records.  This failure resulted in Patient 1, Patient 2, Patient 5, Patient 9, Patient 12, Patient 13, and Patient 14 not having complete clinical records that could potentially not identify the patients’ current health conditions and affect the care and services they received that could lead to hospitalization and death. --- Findings: During a review of the hospice agency’s Patient Discharged Report (a list of patients who were discharged during a set period), dated 7/8/2024 to 7/8/2025, the Patient Discharged Report indicated the following: Patient 1 was admitted on 9/26/2024 with a terminal diagnosis of congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). Patient 1 was discharged on 1/23/2025. Patient 2 was admitted on 3/4/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) with unspecified angina pectoris (chest pain caused by reduced blood flow to the heart muscle).  Patient 2 was discharged on 8/1/2024. Patient 4 was admitted on 5/26/2024 with a terminal disease of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris.  Patient 4 was discharged on 9/25/2024. Patient 5 was admitted on 6/6/2024 with a terminal diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure), with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body’s needs for blood and can result in shortness of breath, fatigue, swollen legs, and rapid heartbeat). Patient 5 discharged on 7/13/2024.  Patient 5 was readmitted on 8/2/2024 with a terminal diagnosis of hypertensive heart disease with heart failure.  Patient 5 was discharged on 8/6/2024.  Patient 6 was admitted on 5/31/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 6 was discharged on 5/31/2025.Patient 7 was admitted on 6/6/2024 with a terminal illness of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 7 was discharged on 5/31/2025.Patient 9 was admitted to the HA on 10/31/2024 with a terminal diagnosis of atherosclerotic heart disease without angina pectoris. Patient 9 was discharged on 11/20/2024. Patient 12 was admitted to the HA on 8/5/2024 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Patient 12 was discharged on 9/30/2024. Patient 13 was admitted to the HA on 11/14/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. Patient 13 was discharged on 7/10/2024. Patient 14 was admitted to the HA on 3/12/2024 with a terminal diagnosis of heart disease (a broad term for conditions affecting the heart and blood vessels), unspecified. Patient 14 was discharged on 3/6/2025. a. During a review of Patient 1’s Certification of Terminal Illness for the certification period from 6/27/2024 through 9/24/2024 (certification #2), the CTI was not signed by the hospice physician. During a review of Patient 1’s Certification of Terminal Illness for the certification period from 9/26/2024 through 11/24/2024 (certification #3), the CTI was not signed by the hospice physician. During a review of Patient 1’s Certification of Terminal Illness for the certification period from 11/25/2024 through 1/23/2025 (certification #4), the CTI was not signed by the hospice physician. During a concurrent interview and record review with Director of Patient Care Services Designee (DPCSD) 2 on 7/14/2025, at 11:47 a.m., DPCSD 2 reviewed the CTI for Patient 1 for the certification period from 6/27/2024 through 9/24/2024 (certification #2), from 9/26/2024 through 11/24/2024 (certification #3), and from 11/25/2024 through 1/23/2025 (certification#4). DPCSD 2 confirmed that the CTI was not signed and dated by the Medical Director or Medical Director Designee. DPCSD 2 stated the CTIs could only be signed and dated by HA’s physician or a physician designee to be considered completed.   b. During a review of Patient 2’s Certification of Terminal Illness for the certification period from 3/4/2024 through 6/1/2024 (certification#1), the CTI was not signed by the hospice physician. During a review of Patient 2’s Certification of Terminal Illness for the certification period from 6/2/2024 through 8/30/2024 (certification #2), the CTI was not signed by the hospice physician. During a concurrent interview and record review with DPCSD 2 on 7/14/2025, at 11:47 a.m., DPCSD 2 reviewed the CTI for Patient 2 for the certification period from 3/4/2024 through 6/1/2024 (1 certification) and 6/2/2024 through 8/30/2024 (certification #2). DPCSD 2 confirmed that the CTI was not signed and dated by the Medical Director or Medical Director Designee. DPCSD 2 stated the CTIs could only be signed and dated by HA’s physician or a physician designee to be considered completed.      c. During a review of Patient 5’s Certification of Terminal Illness for the certification period from 2/16/2024 through 5/15/2025 (certification #1), the CTI was not signed by the hospice physician. During a review of Patient 5’s Certification of Terminal Illness for the certification period from 6/6/2024 through 9/3/2024 (certification #2), the CTI was not signed by the hospice physician. During a review of Patient 5’s Certification of Terminal Illness for the certification period from 8/2/2024 through 9/30/2024 (certification #3), the CTI was not signed by the hospice physician. During a concurrent interview and record review with DPCSD 2 on 7/14/2025, at 11:47 a.m., DPCSD 2 reviewed the CTI for Patient 5 for the certification period from 2/16/2024 through 5/15/2025 (certification #1), 6/6/2024 through 9/3/2024 (certification #2) and from 8/2/2024 through 9/30/2024 (certification #3). DPCSD 2 confirmed that the CTI was not signed and dated by the Medical Director or Medical Director Designee. DPCSD 2 stated the CTIs could only be signed and dated by HA’s physician or a physician designee to be considered completed.   d. During a review of Patient 9’s CTI for the certification period of 10/31/2024 to 1/28/2024 (certification #1), the CTI was not signed by the hospice physician. During a concurrent interview and record review with DPCSD 2 on 7/14/2025, at 11:47 a.m., DPCSD 2 reviewed the CTI for Patient 9 for the certification period of 10/31/2024 to 1/28/2024. DPCSD 2 confirmed that the CTI was not signed and dated by the Medical Director or Medical Director Designee. DPCSD 2 stated the CTIs could only be signed and dated by HA’s physician or a physician designee to be considered completed. e. During a review of Patient 12’s CTI for the certification period of 10/31/2024 to 1/28/2024 (certification #1), the CTI was not signed by the hospice physician. During a concurrent interview and record review with DPCSD 2 on 7/14/2025, at 11:47 a.m., DPCSD 2 reviewed the CTI for Patient 12 for the certification period of 10/31/2024 to 1/28/2024. DPCSD 2 confirmed that the CTI was not signed and dated by the Medical Director or Medical Director Designee. DPCSD 2 stated the CTIs could only be signed and dated by HA’s physician or a physician designee to be considered completed. f. During a review of Patient 13’s CTI for the certification period of 11/14/2023 to 2/11/2024 (certification #1), the CTI was not signed by the hospice physician.During a review of Patient 13’s CTI for the certification period of 2/12/2024 to 5/11/2024 (certification #2), the CTI was not signed by the hospice physician. During a concurrent interview and record review with DPCSD 2 on 7/14/2025, at 11:47 a.m., DPCSD 2 reviewed the CTIs for Patient 13 for the certification period from 11/14/2023 to 2/11/2024 and from 2/12/2024 to 5/11/2024. DPCSD 2 confirmed that the CTIs were not signed and dated by the Medical Director or Medical Director Designee. DPCSD 2 stated the CTIs could only be signed and dated by HA’s physician or a physician designee to be considered completed. g. During a review of Patient 14’s CTI for the certification period of 3/12/2024 to 6/9/2024 (certification #1), the CTI was not signed by the hospice physician. During a review of Patient 14’s CTI for the certification period of 6/10/2024 to 9/7/2024 (certification #2), the CTI was not signed by the hospice physician. During a review of Patient 14’s CTI for the certification period of 11/7/2024 to 1/5/2025 (certification #4), the CTI was not signed by the hospice physician. During a review of Patient 14’s CTI for the certification period of 1/6/2025 to 3/6/2025 (certification #5), the CTI was not signed by the hospice physician. During a concurrent interview and record review with DPCSD 2 on 7/14/2025, at 11:47 a.m., DPCSD 2 reviewed the CTIs for Patient 14 for the certification period of 3/12/2024 to 6/9/2024, 6/10/2024 to 9/7/2024, 11/7/2024 to 1/5/2025, and 1/6/2025 to 3/6/2025. DPCSD 2 confirmed that the CTIs were not signed and dated by the Medical Director or Medical Director Designee. DPCSD 2 stated the CTIs could only be signed and dat ed by HA’s physician or a physician designee to be considered completed.During a review of the HA’s policy and procedure (P & P), titled “Contents of Clinical Record,” revised May 2023, the P & P indicated the clinical record will contain sufficient information to identify the patient, describe the patient’s problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. The P & P indicated the documentation will include:-         Substantiation of the terminal diagnosis and criteria for admission.-         Patient and family/caregiver initial, comprehensive, and ongoing comprehensive assessments.-         Certifications and recertifications of terminal illness including physician narrative and face-to-face encounters as needed.

Upon patient record review, 5 of 5 (Patient #1, 2, 3, 4, 5) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient 1, 2, 3, 4, 5: On admission for hospice services, and subsequently, the patient and/or caregiver was not provided with written information relating to the hospice's policies on advance directives, including a description of California laws. (corrected onsite for active patients)

Upon patient record review, 1 of 5 (Patient #1) 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 Patient 1: The medication list, dated 12.15.2021, indicates the patient uses Refresh tears 1 drop ophthalmic three times daily PRN dry eyes, there is no indication of which eye(s) the drops are to be instilled in.

Upon patient record review, 1 of 5 (Patient #2) 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. Patient 2: Per the medication list, dated 12.14.2021, and on direct observation during the home visit, the patient utilizes oxygen at 2 L/minute BNC continuously. The oxygen equipment is included on the DME list on the plan of care. However, no treatment order is present for the use of oxygen.

Upon patient record review, 1 of 5 (Patient #3) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient 3: On admission for hospice services, a POLST form was obtained, dated 12.27.2021, that indicated the patient's preference for DNR code status. However, the EMR was erroneously marked to indicate the patient's preference as full code CPR code status. This was not updated/corrected on review at subsequent IDG meetings.