Complaint Investigation Report

During today’s visit, the LPA conducted a brief physical plant tour and delivered findings for the above allegation between 01:28 PM. and 02:50 PM.

The allegation of “Resident was admitted to hospice without consent” alleges that Resident #1 (R1) was transferred to a Hospice company without their or their Durable Power of Attorney (DPOA)’s consent. LPA reviewed R1’s file and observed hospice admission paperwork for the Hospice company in question. LPA observed R1’s name and a signature on the admission documents. LPA interviewed R1 and provided them the document for review. R1 confirmed that the signature and the initials on the document did not match their own. LPA interviewed DPOA who confirmed that they did not give consent for R1 to be enrolled in the Hospice company. LPA interviewed staff #1 (S1), the facility Administrator, and the Assistant Administrator. All staff interviewed denied requesting the transfer of R1 onto the Hospice company but were unsure why R1 was enrolled with the company. Based on interviews with witness #1 (W1) LPA confirmed that due to R1’s condition, R1 was mentally unable to consent to signing up for hospice care at the time they were enrolled with the Hospice company. LPA confirmed that at the time R1 was enrolled with the Hospice company, R1 was under the care and supervision of the facility. LPA reviewed documentation from the Department of Health & Human Services which stated that as of 04/07/2025 the Hospice company has had their Medicare provider agreement involuntarily terminated and is no longer operating. Based on the information obtained during interviews and file review there is sufficient evidence to support the allegation of “Resident was admitted to hospice without consent.” Therefore, the allegation is deemed Substantiated at this time.

The Assistant Administrator was unable to come to the facility during today's visit but has designated S1 to sign this report on their behalf. This report was read to the Assistant Administrator via telephone call. The following deficiency was cited (refer to LIC 9099D). A copy of the report was printed, appeal rights were provided, and exit interview was conducted.