Every finding on record at 7 Days Hospice Care

Based on observation, interview, and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Conditions of Participations regarding Patient Rights was met as followed. --- 1. The HA failed to ensure, six of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, and Patient 9) and their representative received notice of their rights in a language that they understood and preferred before admission to hospice care. This failure resulted in patients and their representatives are not aware of their rights and responsibilities as hospice patients and missed opportunity to decline the services. (Refer to L502). 2. The HA failed to ensure one of fourteen sampled patients (Patient 9) were able to elect their attending physician of choice. This failure resulted in patients not being aware of their rights to choose their physician for continued care and services. (Refer to L515). 3. The HA failed to inform four of fourteen sampled patients (Patient 1, Patient 2, Patient 3, and Patient 9) about limitation of other services while receiving hospice services. This failure had the potential to result in confusion and receiving late treatment when requested. (Refer to L519). The cumulative effect of these systemic practices resulted in the hospice agency's failure to protect the rights of admitted patients, who did not qualify for the Medicare hospice benefits.

Based on observation, interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure six of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, and Patient 9) and their representative received notice of their rights in a language that they understood and preferred, before admission to hospice services. This failure resulted in patients and their representatives are not aware of their rights as hospice patients and miss opportunity to refuse hospice services. --- 1.A review of Patient 1s Personal Information sheet, indicated a start of care date on 5/9/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). A joint home visit on 12/13/2023, at 10:40 a.m., with Registered Nurse 2 (RN 2) conducted at Patient 1's home. During an interview at the home visit on 12/13/2023, at 10:54 a.m., with Patient 1s caregiver (CG 3), CG3 stated, Patient 1 became aware of the HA at an adult day care center. CG 3 stated Patient 1 was told there was a program for older adults which gets them help at home, check on their health status, get help with diapers, provide wipes, provide protein drinks, and lotions for the skin. CG 3 stated Patient 1 stopped going to the adult day care center. During an interview at the home visit on 12/13/2023, at 11:15 a.m., with CG 3 stated the admission folder (provided by the agency at the start of care, with written information about the agency, rights and responsibilities, and other resource information) was somewhere in the house and did not know she had to have it available. CG 3 stated the last time a folder was given to Patient 1 was 2 years ago and patient consents were not available at the home. CG 3 stated Patient 1 was not dying, she just had many illnesses. During an interview at the home visit on 12/13/2023, at 11:44 a.m., with Patient 1, Patient 1 stated that the HA told her she was in a program for people that are dying but did not have to be dying to be in the program. Patient 1 stated she informed her daughter. Patient 1 stated that her daughter told her to be careful in what she signs up for. Patient 1 stated a doctor had not told her she was dying. Patient 1 stated a doctor had not told her she had 6 months or less to live. Patient 1 stated she could not read English. During a concurrent interview and record review on 12/15/2023, at 1:04 p.m., with the Administrator and Director of Nurses designee (AD/DD) reviewed Patient 1s records titled, ";Election of Medicare Hospice Benefit", dated 5/9/2022, ";Release of Information and Consent for Treatment", dated 5/9/2022, and ";Patient Acknowledgment", dated 5/9/2022. The records indicated Patient 1 had signed the documents and the written notice of Patients Rights and Responsibilities were explained and left at the home. The information was written in English. The AD/DD stated the documents were written in English and either the family or the nurse who did the assessment translated the documents. The AD/DD stated the medical record did not indicate who had translated the documents. The AD/DD stated the consents should have been in a language the patient could understand so the patient knows the information about hospice care. 2. A review of Patient 2s ";Personal Information" sheet, indicated a start of care date on 4/7/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). During an interview on 12/12/2023 at 1:35 p.m., the receptionist (RP 2) stated she could not find Patient 2s consents for the current admission. During an interview on 12/12/2023 at 2:07 p.m., the AD/DD stated, ";we have to have proof with all services we are providing...its part of her right also", when asked why it was important to have consents on every start of care. 3. A review of Patient 3s ";Personal Information" sheet, indicated a start of care date on 12/19/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). During an interview on 12/14/2023, at 9:00 a.m., Patient 3s daughter (CG 6), CG6 stated Patient 6 was not dying ";shes just old" and she did not know how her mother was enrolled in hospice care. CG 6 stated no doctor has told her and Patient 3 is dying in 6 months or less. CG 6 stated Patient 3 speaks Spanish only and could not read English. During a concurrent interview and record review on 12/15/2023, at 1:04 p.m., the AD/DD reviewed Patient 3s records titled, ";Election of Medicare Hospice Benefit", dated 2/24/2021, ";Release of Information and Consent for Treatment", dated 2/24/2021, ";Release of Information and Consent for Treatment", dated 2/24/2021, and ";Patient Acknowledgment", dated 2/24/2021. The records indicated Patient 3 had signed the documents and the written notice of Patients Rights and Responsibilities were explained and left at the home. The information was written in English. The AD/DD stated the documents were in English and either the family or the nurse who did the assessment translated the documents. The AD/DD stated the medical record did not indicate who had translated the documents. The AD/DD stated the consents should have been in a language the patient could understand so the patient knows the information about hospice care. The AD/DD stated the consent reviewed were from a previous certification period. There were no consents obtained for the current certification period. 4.A review of Patient 4s ";Personal Information" sheet, indicated a start of care date on 10/19/2023, with a primary diagnosis of heart disease. During an interview on 12/14/2023, at 9:35 a.m., Patient 4 stated she learned about the HA when she visited a rehabilitation center, ";they were outside giving a flyer, I asked them if it was legal or not. They told me it was legal because its a Medicare program". Patient 4 stated she was not dying, and no doctor had told her she had 6 months or less to live. Patient 4 stated she had a primary care doctor, with the last visit being on September 30, 2023. Patient 4 stated her primary care doctor said she was okay. 5.A review of Patient 8s medical record form titled ";Patient Information" indicated Patient 8 start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s medical forms titled ";Decline of Specific Services; Patient Acknowledgement; Election of Medicare Hospice Benefit; Release of Information & Consent for Treatment" indicated they were signed by Patient 8s wife/caregiver (CG1) and Registered Nurse 1 (RN1). During a joint home visit 12/13/2023 at 10 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, greeted at door by CG1. CG1 consented to visit. CG1 stated her preferred language was Spanish for both reading and speaking. CG1 stated in Spanish, that the HA staff knew she spoke Spanish and did not know why they provided all their paperwork in English. CG1 stated she would have requested the paperwork in Spanish, but she was not aware that there were provided in English. 6.A review of Patient 9s medical record form titled ";Patient Information" indicated Patient 9 start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). A review of Patient 9s medical forms titled ";Decline of Specific Services; Patient Acknowledgement; Election of Medicare Hospice Benefit; Release of Information & Consent for Treatment" indicated they were signed by Patient 9. During a joint home visit 12/13/2023 at 11:45 a.m. with License Vocational Nurse 1 (LVN1) to Patient 9s home, greeted at door by CG2. CG2 and Patient 9 consented to visit. CG2 stated family friend was visiting to assist with Spanish translation and that both he and his mother prefer Spanish. LVN1 requested Patient 9s family friend for assistance with Spanish translation during home visit. CG2 stated he needed consent in Spanish to be able to read them and understand the services better because he was unaware that hospice services were for people who were dying. During an interview with LVN1 on 12/13/2023 at 11:20 a.m. with LVN1, LVN1 stated Spanish speaking patients needed their consents in Spanish to be able to understand what they are signing and what hospice services are. LVN1 stated she was unaware if hospice services were explained to the patients. LVN1 stated there was possibility patients were not taking medications that could have provided treatment because they did not know what hospice was. A record review of the HAs policy and procedure titled, ";Facilitating Communication", dated 2019, indicated, ";Procedure...5E. Family members or friend of the patient will not be used as interpreters unless specifically requested by the individual and after the patient has understood that an offer of an interpreter at no charge has been made. Such an offer and response will be documented in the patients record...F. Document all language assisted care in the patients clinical record." A record review of the HAs policy and procedure titled, ";Patient Bill of Rights/Responsibilities", dated 2019, indicated, ";Procedure...3. The Patient Bill of Rights/Responsibilities will 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...6C. Written information will be provided to patients in the predominant languages of the population served." A record review of the HAs policy and procedure titled, ";Rights/Responsibilities" dated 1995, indicated ";Each patient will be an active, informed participant in his/her plan of care. To encourage awareness of patient rights and responsibilities to provide guidelines to assess patient making decisions regarding care, and to support active participation in care planning. Upon admission, each hospice patient and/or his/her representative will be given a written copy of the Patient Rights and Responsibilities. This explanation will be in a language that the patient and manager understand."

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 one of fourteen sample patients (Patient 9) were able to elect their attending physician of choice. This failure resulted in patients not being aware of their rights to choose a physician and continued seeing their primary physicians. --- A review of Patient 9s Patient Information indicated Patient 9 start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). During a joint home visit 12/13/2023 at 11:45 a.m. with License Vocational Nurse 1 (LVN1) at Patient 9s home, and an interview with Patient 9's caregiver 2 (CG2), CG2 stated Patient 9 was seeing by her primary physician (MD2 – Medical Doctor 2) in November 2023. CG2 stated neither him nor Patient 9 were given the option to elect a physician. CG2 stated Patient 9 did not need the HAs physician because she had her own. During a telephone interview on 12/13/2023 at 2 p.m. with MD2, MD2 stated Patient 9 was not referred for hospice services. MD2 stated Patient 9s mental status and her physical exams were normal. MD2 stated Patient 9s plan was to follow up with them in 2 months. A record review of the HAs policy and procedure titled, ";Hospice Election Statement", dated 2019, indicated, ";Procedure...3. The patient/representative will be asked to identify the name of the attending physician." A record review of the HAs policy and procedure titled, ";Admission Criteria and Process", dated 2019, indicated, ";Procedure: 1...If the request for service is not made by the patients physician, he/she will be consulted prior to the evaluation visit/initiation of services."

Based on interview and record review the Hospice Agency (HA) failed to inform four of 14 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 9) about limitation of other services while receiving hospice services. This failure had the potential to result in confusion and receiving late treatment when requested. --- a.A review of Patient 1s ";Personal Information" sheet, indicated a start of care date on 5/9/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). During an interview at the home visit on 12/13/2023, at 11:44 a.m., Patient 1 stated the HA told her she was in a program for people that are dying and did not have to be dying to be in the program. Patient 1 stated she informed her daughter and her daughter told her to be careful in what she signs up for. Patient 1 stated a doctor had not told her she was dying. Patient 1 stated a doctor had not told her she had 6 months or less to live. Patient 1 stated she did not know other medical services were not covered while being in hospice care. Patient stated she did not know how to read English. During a concurrent interview and record review on 12/15/2023, at 1:04 p.m., the Administrator and Director of Nurses designee (AD/DD) reviewed Patient 1s Patient Acknowledgment dated 5/9/2022. The records indicated Patient 1 had signed the documents and the written notice of Consent, Assignment of Benefits were explained and left at the home. The written notice of Consent, Assignment of Benefits information was written in English. The AD/DD stated the documents were in English and either the family or the nurse who did the assessment translated the documents. The AD/DD stated the medical record did not indicate who had translated the documents. The AD/DD stated the consents should have been in a language the patient could understand so the patient knows the information about hospice care. 2.A review of Patient 2s Personal Information sheet, indicated a start of care date on 4/7/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). During an interview on 12/12/2023 at 1:35 p.m., the receptionist (RP 2) stated she could not find Patient 2s consents for the current admission. During an interview on 12/12/2023 at 2:07 p.m., the AD/DD stated, ";we have to have proof with all services we are providing...its part of her right also", when asked why it was important to have consents on every start of care. 3. A review of Patient 3s Personal Information sheet, indicated a start of care date on 12/19/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). During an interview on 12/14/2023, at 9:00 a.m., Patient 3s daughter (CG 6) stated she did not know how her mother was enrolled in hospice care because Patient 3 was not dying. CG 6 stated no doctor has told her and her mother Patient 3 is dying in 6 months or less. CG 6 stated her mother was not dying, ";shes just old". CG 6 stated Patient 3 speaks Spanish only and does not read English. During a concurrent interview and record review on 12/15/2023, at 1:04 p.m., the AD/DD reviewed Patient 3s records titled, ";Election of Medicare Hospice Benefit", dated 2/24/2021, ";Release of Information and Consent for Treatment", dated 2/24/2021, ";Release of Information and Consent for Treatment", dated 2/24/2021, and ";Patient Acknowledgment", dated 2/24/2021. The records indicated Patient 3 had signed the documents and the written notice of Patients Rights and Responsibilities were explained and left at the home. The information was written in English. The AD/DD stated the documents were in English and either the family or the nurse who did the assessment translated the documents. The AD/DD stated the medical record did not indicate who had translated the documents. The AD/DD stated the consents should have been in a language the patient could understand so the patient knows the information about hospice care. The AD/DD stated the consent reviewed were from a previous certification period. There were no consents obtained for the current certification period. 4. A review of Patient 9s Patient Information indicated Patient 9 start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). During a joint home visit 12/13/2023 at 11:45 a.m. with License Vocational Nurse 1 (LVN1) to Patient 9s home, greeted at door by CG2. CG2 and Patient 9 consented to visit. CG2 stated Patient 9 was seeing by her primary physician (MD2 – Medical Doctor 2) in November 2023. CG2 stated neither him nor Patient 9 were given the option to elect a physician. CG2 stated Patient 9 did not need the HAs physician because she had her own. During a telephone interview on 12/13/2023 at 2 p.m. with MD2, MD2 stated Patient 9 was not referred for hospice services. MD2 stated Patient 9s mental status and her physical exams were normal. MD2 stated Patient 9s plan was to follow up with them in 2 months. A record review of the HAs policy and procedure titled, ";Patient Bill of Rights/Responsibilities", dated 2019, indicated, ";Procedure...3. The Patient Bill of Rights/Responsibilities will 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... A record review of the HAs policy and procedure titled, ";Medicare Hospice Benefit", dated 2019, indicated, ";Policy...The Medicare hospice benefit is a total package of care for all medical needs associated with the patients terminal illness. Therefore, the patient gives up the right to coverage for other Medicare benefits, such as hospital and hospice care from other agencies. The patient must also acknowledge an understanding that hospice is a program of care that emphasizes comfort, not cure."

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Conditions of Participations regarding initial and Comprehensive Assessments of Patients was met as follows: --- 1. The HA staff failed to conduct and document an initial assessment identifying the need for hospice care and services for eight of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, and Patient 11). These patients did not have life expectancy of six months or less, and had no documented need for physical, psychosocial, emotional, or spiritual care. (Refer to L 522). 2. The HA failed to ensure the interdisciplinary group (IDG, meeting where the Registered Nurse [RN], Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after hospice election for five of fourteen sample selected patients (Patient 7, Patient 8, Patient 11, Patient 13, and Patient 14). (Refer to L 523). 3. The HA staff failed to review all medications the patients were taking and update their medication profiles with the currently used medications for three of fourteen sample selected patients (Patient 1, Patient 8, and Patient 9). The patients were at risk for medication errors and adverse drug reactions. (Refer to L 530). 4. The HA failed to conduct or attempt to conduct a bereavement (the period after a loss and the supportive services provided to the family unit to assist it in coping with the patient's death) assessment to provide bereavement counseling in accordance with the patient/family's needs for eleven of fourteen sample selected patients (Patient 1, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) which focused on the social, spiritual, and cultural factors that may affect the ability of the family and other individuals involved in the care, to cope with the patients death. (Refer to L 531). 5. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days thirteen of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L 533). The cumulative effect of these systemic practices resulted in the hospice agency admitting patients who did not meet admission criteria and did not qualify for the Medicare hospice benefit.

Based on observation, interview and record review , the HA failed to ensure an initial assessment (is to gather the critical information necessary to treat the patient/familys immediate care needs) that reflected the patients current health status and need for hospice care (focuses on the palliation [specialized medical care for people living with a serious illness] of attend to their emotional and spiritual needs at the end of life and prioritizes comfort and quality of life by reducing pain and suffering) and services, related to hospice eligibility and management of terminal illness was conducted for eight of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, and Patient 11). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- 1.A review of Patient 1s Personal Information sheet, indicated a start of care date on 5/9/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). During an observation of a home visit on 12/13/2023, at 10:40 a.m., Registered Nurse 2 (RN 2) provided care to Patient 1. During an interview at the home visit conducted on 12/13/2023, at 10:57 a.m., with Registered Nurse 2 (RN 2), Patient 1's caregiver (CG 3) was interviewed. CG 3 stated she accompanied Patient 1 to the mall to walk and Patient 1 used a walker to walk slowly at the mall. CG 3 stated Patient 1 did not have shortness of breath when walking at the mall or when walking two blocks around her home. During an interview at the home visit on 12/13/2023, at 11:15 a.m., with Patient 1, Patient 1 stated that the HA provided oxygen but did not use it. Patient 1 state the last time she used oxygen was 6 months ago when she was sick. Patient 1 stated she did not need oxygen when walking. During an interview at the home visit on 12/13/2023, at 11:44 a.m., Patient 1 stated no doctor had told her she was dying. Patient 1 stated no doctor had told her she had 6 months or less to live. During an interview at the home visit on 12/13/2023, at 12:00 p.m., Patient 1s daughter (CG 4) stated she did not know her mother was in hospice care. CG 4 stated her mother was not dying and thought the nurse who was visiting her was from the insurance plan, not a hospice agency. During a concurrent interview and record review on 12/15/2023, at 11:38 a.m., with the Administrator/Director of Nurses designee (AD/DD), AD/DD reviewed Patient 1s record titled, Comprehensive Nursing Assessment, dated 5/9/2022. The record indicated the Local Criteria Determination (LCD, a tool used to qualify a patient for hospice care services) indicated Patient 1 was eligible for hospice care services because Patient 1 had been ruled out as a candidate for surgical procedures and her Congestive Heart Failure (CHF) met the criteria for NYHA (New York Heart Association-classifies the extend of heart failure) class IV (4) level (Class IV-severe limitation. Experiences symptoms even while at rest. Mostly bedbound patients.) The AD/DD stated the information used to complete the LCD was gathered from the referring doctor. The AD/DD stated there were no medical records to support the diagnosis. The AD/DD stated the assessment was not accurate because the HA did not have supportive documents to support Patient 1s diagnosis. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. By being in hospice, Patient 1 might not be eligible for other services. Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 1 might need. 2.A review of Patient 2s Personal Information sheet, indicated a start of care date on 4/7/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). During an interview on 12/14/2023 at 8:55 a.m., Patient 2s daughter (CG 5) stated it was for Patient 2 to be in hospice care, as she was not supposed to be in the hospice program. CG 5 stated Patient 2 was not dying, as no doctor had told her and Patient 2 she had 6 months or less to live. CG 5 stated she informed the HA her mother did not need hospice services, since her mother was not terminal, and has never been considered terminal. During a concurrent interview and record review on 12/15/2023, at 11:48 a.m., the AD/DD reviewed Patient 2s record titled, Comprehensive Nursing Assessment, dated 4/7/2023. The record indicated the LCD indicated Patient 2 was eligible for hospice care services due to inability to carry out activities of daily living and inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months. The AD/DD stated there was no documents such as a history and physical (a document that explains the past and current medical history, assessment findings, and plan), doctors notes, or test results to support a diagnosis of Alzheimers disease. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. By being in hospice, Patient 2 might not be eligible for other services. Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 2 might need. 3. A review of Patient 3s Personal Information sheet, indicated a start of care date on 12/19/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). During an interview on 12/14/2023, at 9:00 a.m., with Patient 3s daughter (CG 6), CG6 stated she did not know how her mother was enrolled in hospice care because Patient 3 was not dying. CG 6 stated no doctor has told her that Patient 3 was dying in 6 months or less. CG 6 stated her mother was not dying, ";shes just old". During a concurrent interview and record review on 12/15/2023, at 11:54 a.m., the AD/DD reviewed Patient 3s record titled, Comprehensive Nursing Assessment, dated 12/29/2022. The record indicated the LCD indicated Patient 3 was eligible for hospice care services because Patient 3 had been ruled out as a candidate for surgical procedures, declined surgical procedures and CHF met the criteria for NYHA class IV (4).. The AD/DD stated she did not know where the information came from. The AD/DD stated there were no medical records to support the diagnosis and findings of heart failure. The AD/DD stated the assessment was not accurate because the HA did not have supportive documents to support Patient 3s diagnosis. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient's eligibility for hospice care. The AD/DD stated Patient 3 might not be eligible for hospice care and services. 4. A review of Patient 4s Personal Information sheet, indicated a start of care date on 10/19/2023, with a primary diagnosis of heart disease. During an interview on 12/14/2023, at 9:35 a.m., Patient 4 stated she learned about the HA when she visited a rehabilitation center, ";they were outside giving a flyer, I asked them if it was legal or not. They told me it was legal because its a Medicare program". Patient 4 stated she was not dying, and no doctor had told her she had 6 months or less to live. Patient 4 stated she had a primary care doctor, with the last visit being on September 30, 2023. Patient 4 stated her primary care doctor said she was okay. Patient 4 stated she was able to walk with a cane, did not need oxygen, was able to dress and shower by herself. During a concurrent interview and record review on 12/15/2023, at 11:58 a.m., with the AD/DD, AD/DD reviewed Patient 4s record titled, Comprehensive Nursing Assessment, dated 10/19/2023. Patient 4's Comprehensive Nursing Assessment, record indicated Patient 4 was eligible for hospice care services because Patient 4 had declined surgical procedures, was treated for heart disease with diuretics (medications that get rid of excess water in the body), and vasodilators (medications that lower the blood pressure) and CHF met the criteria for NYHA class IV (4). The AD/DD stated she did not know where the information came from. The AD/DD stated there were no medical records to support the diagnosis and findings of heart failure. The AD/DD stated the assessment was not accurate because the HA did not have supportive documents to support Patient 4s diagnosis. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. By being in hospice, Patient 4 might not be eligible for other services. Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 4 might need. 5.A review of Patient 5s Personal Information sheet, indicated a start of care date on 12/18/2020, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). During a concurrent interview and record review on 12/15/2023, at 11:59 a.m., the AD/DD reviewed Patient 5s record titled, Comprehensive Nursing Assessment, dated 12/18/2020. The Patient 5's Comprehensive Nursing Assessment indicated Patient 5 was eligible for hospice care services due to inability to carry out activities of daily living and inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months. The AD/DD stated there was no medical documents to support a diagnosis of Alzheimers disease. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. THe AD/DD stated Patient 5 might not be eligible for other services and Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 5 might need. 6.A review of Patient 8s Patient Information indicated Patient 8 start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). It also indicated there were no other diagnoses documented. A review of Patient 8s Comprehensive Nursing Assessment dated 7/15/2022, indicated ";patient is appropriate for hospice care". Patient 6's Comprehensive Nursing Assessment indicated that there was no need for an interpreter. During a joint home visit on 12/13/2023 at 10 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, Patient 8s Care Giver (CG1) stated she or Patient 8 had never been told Patient 8 had six months or less to live. CG1 stated Patient 8 is not dying. CG1 stated Patient 8 was diagnosed with diabetes (high blood sugar) about ten years ago and has been taking medications for it since. CG1 stated she was unable to speak English and required an interpreter. LVN1 called an HA interpreter to assist with translation. During an interview on 12//2023 at 11:20 a.m. with the Administrator/Director of Nurses Designee (AD/DD) of Patient 8s medical record, AD/DD stated all of Patient 8s diagnoses should be documented in his plan of care, including diabetes (high blood sugar) and hypertension (high blood pressure). 7. A review of Patient 9s Patient Information indicated Patient 9 start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). A review of Patient 9s Comprehensive Nursing Assessment dated 6/11/2023, indicated there was no need for an interpreter. It also indicated Patient 9 was completely dependent on ambulation and transfer. It also indicated under section ";Narrative & Disease Trajectory – the patient and family wishes no further aggressive treatment and has now opted for hospice acre for palliative measures, symptoms management and comfort care only. Patient is appropriate for hospice care..." During a joint home visit on 12/13/2023 at 11:45 a.m. with License Vocational Nurse 1 (LVN1) to Patient 9s home, Patient 9 noted sitting on couch in living room, got off from couch and excused herself to the restroom, then ambulated unassisted. Patient 9 stated she ambulates around her street block every day to maintain healthy. Patient 9s Care Giver (CG2) stated he or Patient 9 had never been told Patient 9 had six months or less to live. CG2 stated Patient 9 is not dying. CG2 stated Patient 9 was seen by her primary physician a month ago for her yearly physical and they stated she was doing fine. CG2 stated they were not aware Patient 9 had a hospice doctor and stated hospice doctor was not needed because she had her own. CG2 stated he speaks limited English and required an interpreter. 8. A review of Patient 11s Patient Information indicated Patient 11 start of care date of 10/20/2023, with diagnoses including cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). A review of Patient 11s medical record form titled ";Comprehensive Nursing Assessment" dated 10/20/2023, indicated Patient 11 was completely dependent on dressing, bathing, ambulation, and transfer, had slurred speech and was chairfast. It also indicated under section ";Narrative & Disease Trajectory – the patient and family wishes no further aggressive treatment and has now opted for hospice acre for palliative measures, symptoms management and comfort care only. Patient is appropriate for hospice care..." During a telephone interview on 12/13/2023 at 4:21 p.m. with Patient 11s Caregiver 7 (CG7), CG7 stated neither Patient 11 or her have been told Patient 11 had six months or less to live. CG7 stated Patient 11 is not dying. CG7 stated Patient 11 was outside getting the mail but is in home now and handed phone over to Patient 11. Patient 11 stated he walked about a block away to get his mail. Patient 11 stated he was able to use the restroom, get dressed, brushed his teeth, cook, and eat by himself. Patient 11 stated he was not aware of what hospice services were. A record review of the HAs policy and procedure titled, ";Initial Assessment", dated 2019, indicated ";An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care...the initial assessment will be included as a part of the comprehensive assessment". A record review of the HAs policy and procedure titled, ";Comprehensive Assessment", dated 2019, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented...including at least... nature and condition causing admission... laboratory results...Past medical and surgical care... The assessment should determine probable prognosis of six (6) months or less..." A record review of the HAs policy and procedure titled, ";Admission Criteria and Process", dated 2019, indicated, ";The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determinations (LCDs). (HA) will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician, if any... The patients physician must order and approve the provision of hospice care... 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 interdisciplinary group (IDG – meeting where the Registered Nurse [RN], Medical Social Worker [MSW], Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after hospice election for five of 14 sampled patients (Patient 7, Patient 8, Patient 11, Patient 13, and Patient 14). This deficient practice had the potential for the patients (Patient 7, Patient 8, Patient 11, Patient 13, and Patient 14). not receiving appropriate healthcare services that could affect their quality of life. --- 1.A review of Patient 7s Personal Information sheet, indicated a start of care date on 9/14/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). The record further indicated an end of care date of 9/16/2023, due to death. During a concurrent interview and record review on 12/15/2023, at 11:25 a.m., the Administrator/Director of Nurses Designee (AD/DD) reviewed Patient 7s clinical records. The AD/DD stated a spiritual assessment had not been done for Patient 7 and did not know why it was not done. During a concurrent interview and record review on 12/15/2023, at 11:25 a.m., the AD/DD reviewed Patient 7s clinical records. The AD/DD stated a psychosocial assessment had not been done for Patient 7 and did not know why it was not done. The AD/DD stated the assessment was supposed to be done within a few days by the social worker. The importance of the assessment is because it is part of the plan of care. The HA has to know what needs Patient 7 has. The HA did not know the needs because it the psychosocial assessment was not done. 2.A review of Patient 8s Patient Information indicated Patient 8 start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s Plan of Care /Interdisciplinary Group (POC/IDG) Review dated 7/15/2022, indicated section medical social worker (MSW) signature was blank and Patient 8s language barrier was not addressed/documented. During a joint home visit 12/13/2023 at 10 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, greeted at door by Caregiver 1 (CG1). CG1 consented to visit. CG1 stated her preferred language was Spanish for both reading and speaking. CG1 stated in Spanish, that the HA staff knew she spoke Spanish and does not know why they provided all their paperwork in English. CG1 stated she would have requested the paperwork in Spanish, but she was not aware that there were provided in Spanish. LVN1 called Interpreter 1 (IP1) to assist with Spanish translation during home visit. 3.A review of Patient 11s Patient Information indicated Patient 11 start of care date of 10/20/2023, with diagnoses including cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). A review of Patient 11s POC/IDG Review dated 10/20/2023, indicated section ";MSW" signature and RN signature were blank. 4.A review of Patient 13s Patient Information indicated Patient 13 start of care date of 4/1/2021, with diagnoses including malignant neoplasm (cancer) of prostate. A review of Patient 13s POC/IDG Review dated 4/1/2023, indicated section MSW signature was left blank. 5.A review of Patient 14s Patient Information indicated Patient 14 start of care date of 7/20/2023, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 14s POC/IDG Review dated 7/20/2023, indicated section MSW signature was left blank. During an interview on 12/14/2023 at 12:45 p.m. with the Administrator/Director of Nurses Designee (AD/DD), AD/DD stated IDG members were the admitting nurse, social worker, chaplain, and medical director. AD/DD stated patients initial IDG meeting should be completed 48 hours after admission to be able to complete the patients' plan of care (POC). AD/DD stated initial IDG meetings are a discussion of patients care needs. AD/DD stated the disciplines involved in the IDG meeting need to document under their discussion section and sign the form. AD/DD stated disciplines signatures prove that they attended the meetings. A record review of the HAs policy and procedure titled, ";Psychosocial Assessment", dated 2019, indicated, ";Policy: A thorough psychosocial assessment will be initiated at the time of admission and continued throughout the course of care". A record review of the HAs policy and procedure titled, ";The Plan of Care" dated 2019, indicated ";A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care...The plan of care will be reviewed prior to care being delivered. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care." A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities", dated 2019, indicated ";The hospice interdisciplinary team/group members will include, at a minimum: Physician, Registered Nurse, Social Worker, Pastoral... The interdisciplinary group will: participate in the establishment of the plan of care..."

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) staff failed to review all medications the patients were taking and update their medication profiles with the currently used medications for three of 14 sampled patients (Patient 1, Patient 8, and Patient 9). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions when the medication not administered as ordered by the physician. --- 1.A review of Patient 1s Personal Information sheet, indicated a start of care date on 5/9/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). During a concurrent observation, interview, and record review on 12/13/2023, at 11:15 a.m., with Registered Nurse 2 (RN 2), RN 2 reviewed Patient 1s medications using record titled, ";Current Treatment/Medication/DME List", printed on 12/12/2023. The following medications were not listed on the medication list: Cetirizine-used for allergies Simvastatin-to lower cholesterol (fat) levels in the blood Hydroxychloroquine-for rheumatic arthritis Allopurinol-decreases uric acid levels in the blood Tolterodine-for overactive bladder Myrbetriq-for overactive bladder Amlodipine-lowers blood pressure Fluticasone-for fungal infections Tramadol-treatment for pain During an interview, and record review on 12/13/2023, at 11:15 a.m., with RN 2, RN 2 stated the following medications were listed on the record, but Patient 1 was no longer taking: Pro Air-relaxes the lungs, to make it easier to breathe. Duo-neb-bronchodilator relaxes the lungs, to make it easier to breathe. Singulair-to prevent asthma attacks. Albuterol-relaxes the lungs, to make it easier to breathe. RN 2 stated medication ";Mirtazapine" (a medication used to treat depression), dosage was listed wrong in the record. The medication in Patient 1s home was 15 mg (mg-unit of measurement) and the dosage on record was 30 mg. RN 2 stated she needed to see why there was two different doses. 2.A review of Patient 8s Patient Information indicated Patient 8 start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s medical record form titled ";Current Treatment/Medication/DM List" indicated ";Tylenol liquid (pain/fever reducer medication), Seroquel (agitation medication), Ferrous Sulfate (iron supplement), Refresh eye drops, Acetaminophen (pain/fever reducer medication), Diclofenac Sodium 1% topical gel (pain medication), Zyrtec (allergy medication), and Duoneb (congestion medication)" were listed on the form. During a joint home visit on 12/13/2023 at 10 a.m. with License Vocational Nurse 1 (LVN1) at Patient 8s home, LVN1 requested Patient 8s Caregiver 1 (CG1) to provide all of Patient 8s medications. CG1 provided list of medications Patient 8 currently takes. LVN 1 stated she did not complete a medication reconciliation for Patient 8 because she did not have a current medication list. LVN1 stated she requested HA to provide Patient 8s current medication list but they had not. LVN1 stated medication reconciliation should be done at every nursing home visit because the patient could be missing prescribed medications or could be taking medication the HA is unaware of. CG1 stated Patient 8 was not currently taking the medication listed on the medication form: Tylenol liquid, Seroquel, Ferrous Sulfate, Refresh eye drops, Acetaminophen, Diclofenac Sodium 1% topical gel, Zyrtec, and Duoneb. 3.A review of Patient 9s Patient Information indicated Patient 9 start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). A review of Patient 9s Current Treatment/Medication/DM List indicated ";Isosorbide Mononitrate (chest pain medication), Nitroglycerine 0.3mg (chest pain medication), Vitamin D (supplement), Maxitrol (anti-infective medication), Cefdinir (anti-infective medication), Escitalopram (depression medication)." During a joint home visit on 12/13/2023 at 11:45 a.m. with License Vocational Nurse 1 (LVN1) to Patient 9s home, LVN1 requested Patient 9s Caregiver 2 (CG2) to provide all of Patient 9s medications. Discrepancies between medication list and medication bottle labels as follows: 1. Medication List: Isosorbide Mononitrate (chest pain medication), once daily Medication label: Isosorbide dinitrate (heart failure medication), twice a day 2. Medication list: Nitroglycerine 0.3mg Medication label: Nitroglycerine 0.4mg 3. Medication list: Vitamin D Medication label: Vitamin D3 Medications listed Patient 9s medication list which CG2 stated Patient 9 does not take: 1. Maxitrol every 6 hours x7 days for infection ordered date 6/18/2023 CG2 stated Patient 9 has not used since January 2023 2. Cefdinir twice daily for 7 days CG2 stated Patient 9 has not used since January 2023 3. Escitalopram once daily CG2 stated last time Patient 9 took was in March 2023, stated she does not need the medication because she is not depressed. CG2 stated Patient 9s UTI (urinary tract infection) and eye infections were cleared in January 2023. LVN1 instructed/educated Patient 9 and CG2 to place one tab of Nitroglycerine under the tongue when chest pain occurs. If pain continues to take another after 15 minutes, and if pain continues to take one last tablet after 15 minutes. LVN1 was asked by surveyor to look at medication bottle label which stated, ";to take every 5 minutes". LVN1 stated it should be every 15 minutes and that she did not know why they put every 5 minutes on the label or the medication list. CG2 provided the following medication that were not listed on Patient 9s medication list: 1. Omeprazole 40 mg one tab daily – fill date 9/21/2023. 2. Seroquel 25 mg one tab at bedtime – fill date 11/6/2023. The HA failed to reconciliate Patient 9s medication to reflect currently used medications. During an interview on 12/13/2023 at 1 p.m. with LVN1, LVN1 stated she checks patients medications for doses, expiration dates, medication name, frequency, persons name, and route. LVN1 stated ";We have to check because patients can make mistakes, they need to know what they are taking and what it is for." During an interview on 12/14/2023 at 12:45 p.m. with Administrator/Director of Nurses Designee (AD/DD). AD/DD stated patients medications should be reconciled at every skilled nursing visit. AD/DD stated the nurse should check all the patients medications to avoid medication errors that can harm the patient. A review of National Institute of Health, revised 2/2020, Nitroglycerin. Retrieved 12/23/2023, from https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=763ce792-c991-f472-e053-2a91aa0a77dd&type=display, indicated ";One tablet should be dissolved under the tongue or in the buccal pouch at the first sign of an acute anginal attack. The dose may be repeated approximately every 5 minutes until relief is obtained. If the pain persists after a total of 3 tables in a 15-minute period..." A record review of the HAs policy and procedure titled, ";Medication Profile" dated 2019, indicated ";Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. Procedure...3. During subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen.

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 conduct a bereavement assessment to provide bereavement counseling in accordance with the patient/family's needs for eleven of 14 sampled patients (Patient 1, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This deficient practice had the potential to impact a family members' abilities to cope with the patients' death --- 1.A review of Patient 1s Personal Information sheet, indicated a start of care date on 5/9/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). During a concurrent interview and record review on 12/12/2023, at 1:00 p.m., with the volunteer coordinator (VC), the CV reviewed Patient 1s clinical record and stated the initial bereavement assessment had not been done for Patient 1. 2.A review of Patient 5s Personal Information sheet, indicated a start of care date on 12/18/2020, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). During a concurrent interview and record review on 12/12/2023, at 1:00 p.m., with the VC, the VC reviewed Patient 5s clinical record and stated the initial bereavement assessment had not been done for Patient 5. 3.A review of Patient 6s Personal Information sheet, indicated a start of care date on 6/3/2021, with a primary diagnosis of heart disease. During a concurrent interview and record review on 12/12/2023, at 1:00 p.m., with the VC, the VC reviewed Patient 6s clinical record and stated the initial bereavement assessment had not been done for Patient 6. 4.A review of Patient 7s Personal Information sheet, indicated a start of care date on 9/14/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). The record further indicated an end of care date of 9/16/2023, due to death. During a concurrent interview and record review on 12/12/2023, at 1:00 p.m., with the VC, the VC reviewed Patient 7s clinical record and stated the initial bereavement assessment had not been done for Patient 7. During a concurrent interview and record review on 12/15/2023, at 11:27 a.m., the Administrator/Director of Nurses designee (AD/DD) reviewed Patient 7s clinical records. The AD/DD stated a bereavement assessment had not been done for Patient 7 and did not know why it was not done. The importance of the assessment was to know what the bereavements needs of the patient and family were, so staff know the steps needed to meet those needs. 5.A review of Patient 8s Patient Information indicated Patient 8 start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s Comprehensive Nursing Assessment dated 7/15/2022, indicated social worker (SW), spiritual Counselor (SC), and Bereavement Counselor (BC) visits were needed. A review of Patient 8s ";POC/IDG Review" dated 11/29/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: patients primary bereaved will experience non-complicated grieving process, and bereaved will verbalized accepting of terminal diagnosis by next recertification. Intervention: will continue to follow up for any changes in grieving process. Assist family with grieving process. Assist primary bereaved in coping with the dying process and death and re-assess post death bereavement. Offer encouraging tips and resources to get through grief. Attentive listening, understand their loss. Offer encouraging tips to get through grief." A review of Patient 8s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no assessments documented; form was blank. During a concurrent interview and record review on 12/12/2023 at 4 p.m. with the Volunteer Coordinator (VC) of Patient 8s Electronic Medical Record (EMR), VC coordinator stated Patient 8 did not have any bereavement assessments documented. During an interview on 12/14/2023 at 12:45 p.m. with AD/DD, AD/DD stated initial bereavement assessments should be completed by either the chaplain or the social worker within five days of admission. AD/DD stated if not completed staff would not know who needs the bereaved services and can cause the family to get frustrated and unhappy 6.A review of Patient 9s Patient Information indicated Patient 9 start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). A review of Patient 9s Comprehensive Nursing Assessment dated 6/11/2023, indicated SW, SC, and BC visits were needed. A review of Patient 9s ";POC/IDG Review" dated 11/29/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: patients primary bereaved will experience non-complicated grieving process, and bereaved will verbalized accepting of terminal diagnosis by next recertification. Intervention: will continue to follow up for any changes in grieving process. Assist family with grieving process. Assist primary bereaved in coping with the dying process and death and re-assess post death bereavement. Offer encouraging tips and resources to get through grief. Attentive listening, understand their loss. Offer encouraging tips to get through grief. A review of Patient 9s ";Bereavement Assessment" dated 7/7/2023, indicated form was not completed. It also indicated there was no documentation in the ";Narrative Section" and it was not signed by HA staff. During a concurrent interview and record review on 12/12/2023 at 4 p.m. with the Volunteer Coordinator (VC) of Patient 9s Electronic Medical Record (EMR), VC coordinator stated Patient 9 did have a bereavement assessment dated 7/7/2023, but it was not completed, and it was not signed by HA staff. VC stated she did not know who started the documentation on the form and that it should have been completed within five days of admission. 7.A review of Patient 10s Patient Information indicated Patient 10 start of care date of 11/3/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 10s Comprehensive Nursing Assessment dated 11/3/2021, indicated SW, SC, and BC visits were needed. A review of Patient 10s ";POC/IDG Review" dated 11/29/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: patients primary bereaved will experience non-complicated grieving process, and bereaved will verbalized accepting of terminal diagnosis by next recertification. Intervention: will continue to follow up for any changes in grieving process. Assist family with grieving process. Assist primary bereaved in coping with the dying process and death and re-assess post death bereavement. Offer encouraging tips and resources to get through grief. Attentive listening, understand their loss. Offer encouraging tips to get through grief. A review of Patient 10s ";History of Bereavement Assessment" undated, indicated there were no assessments documented; form was blank. During a concurrent interview and record review on 12/12/2023 at 4 p.m. with the Volunteer Coordinator (VC) of Patient 10s Electronic Medical Record (EMR), VC coordinator stated Patient 10 did not have any bereavement assessments documented. 8.A review of Patient 11s Patient Information indicated Patient 11 start of care date of 10/20/2023, with diagnoses including cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). A review of Patient 11s Comprehensive Nursing Assessment dated 10/20/2023, indicated SW, SC, and BC visits were needed. A review of Patient 11s ";POC/IDG Review" dated 11/29/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: patients primary bereaved will experience non-complicated grieving process, and bereaved will verbalized accepting of terminal diagnosis by next recertification. Intervention: will continue to follow up for any changes in grieving process. Assist family with grieving process. Assist primary bereaved in coping with the dying process and death and re-assess post death bereavement. Offer encouraging tips and resources to get through grief. Attentive listening, understand their loss. Offer encouraging tips to get through grief. A review of Patient 11s ";History of Bereavement Assessment" undated, indicated there were no assessments documented; form was blank. During a concurrent interview and record review on 12/12/2023 at 4 p.m. with the Volunteer Coordinator (VC) of Patient 11s Electronic Medical Record (EMR), VC coordinator stated Patient 11 did not have any bereavement assessments documented. 9.A review of Patient 12s Patient Information indicated Patient 12 start of care date of 1/13/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 12s Comprehensive Nursing Assessment dated 1/13/2021, indicated SW, SC, and BC visits were needed. A review of Patient 12s ";POC/IDG Review" dated 1/13/2021, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: complete initial bereavement assessment in 5 days. Intervention: Assist family with grieving process. Assist primary bereaved in coping with the dying. Attentive listening, understand their loss. Offer encouraging tips to get through grief. A review of Patient 12s ";History of Bereavement Assessment" undated, indicated there were no assessments documented; form was blank. During a concurrent interview and record review on 12/12/2023 at 4 p.m. with the Volunteer Coordinator (VC) of Patient 12s Electronic Medical Record (EMR), VC coordinator stated Patient 12 did not have any bereavement assessments documented. 10.A review of Patient 13s Patient Information indicated Patient 13 start of care date of 4/1/2021, with diagnoses including malignant neoplasm (cancer) of prostate. A review of Patient 13s Comprehensive Nursing Assessment" dated 4/1/2023, indicated SW, SC, and BC visits were needed. A review of Patient 13s ";POC/IDG Review" dated 6/22/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: patients primary bereaved will experience non-complicated grieving process, and bereaved will verbalized accepting of terminal diagnosis by next recertification. Intervention: will continue to follow up for any changes in grieving process. Assist family with grieving process. Assist primary bereaved in coping with the dying process and death and re-assess post death bereavement. Offer encouraging tips and resources to get through grief. Attentive listening, understand their loss. Offer encouraging tips to get through grief. A review of Patient 13s ";History of Bereavement Assessment" undated, indicated there were no assessments documented; form was blank. During a concurrent interview and record review on 12/12/2023 at 4 p.m. with the Volunteer Coordinator (VC) of Patient 13s EMR, VC coordinator stated Patient 13 did not have any bereavement assessments documented. 11. A review of Patient 14s Patient Information indicated Patient 14 start of care date of 7/20/2023, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 14s ";POC/IDG Review dated 9/9/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: patients primary bereaved will experience non-complicated grieving process, and bereaved will verbalized accepting of terminal diagnosis by next recertification. Intervention: will continue to follow up for any changes in grieving process. Assist family with grieving process. Assist primary bereaved in coping with the dying process and death and re-assess post death bereavement. Offer encouraging tips and resources to get through grief. Attentive listening, understand their loss. Offer encouraging tips to get through grief. A review of Patient 14s ";History of Bereavement Assessment" undated, indicated there were no assessments documented; form was blank. During a concurrent interview and record review on 12/12/2023 at 4 p.m. with the Volunteer Coordinator (VC) of Patient 14s Electronic Medical Record (EMR), VC coordinator stated Patient 14 did not have any bereavement assessments documented. During a concurrent interview and record review on 12/15/2023 at 12:40 p.m. with the Administrator/Director of Nurses Designee (AD/DD) of Patient 14s medical record, AD/DD stated Patient 14 end of care date was on 9/9/2023 due to death. AD/DD stated Patient 14s did not have a bereavement assessment, including a post bereavement assessment. AD/DD stated the social worker had a responsibility to call Patient 14s family after her death. AD/DD stated social services had to be involved to provide support to the family and to assess if additional support was needed. During an interview on 12/14/2023 at 12:45 p.m. with AD/DD, AD/DD stated initial bereavement assessments should be completed by either the chaplain or the social worker within five days of admission. AD/DD stated if not completed staff would not know who needs the bereaved services and can cause the family to get frustrated and unhappy. During a telephone interview on at 10:43 a.m. with Medical Social Worker 2 (MSW2), MSW2 stated she assist patient and their families with resources, emotional support, paperwork, Medicare, and her main job is to provide support and listen to them vent out their feelings and concerns. MSW2 stated she has five days to complete and document an initial psychosocial, initial bereavement, and recertification assessments. MSW2 stated she is responsible for assessing their initial bereavement assessment within five days of admission. A review of facilitys public brochure, undated, indicated ";The Hospice Bereavement Coordinator works with the family and develops a plan to support and help them during their time of loss. The Bereavement Coordinator is a specialist who is aware of the difficulties and needs of a family as they go through this time of loss. Social work and chaplain visits to assist with final arrangements and bereavement care afterwards." A record review of the HAs policy and procedure titled, ";Bereavement Assessment", dated 2019, indicated ";Procedure: 1. On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment... 4. the Bereavement Coordinator will review the bereavement risk assessment to determine potential needs of the survivors."

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 (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for thirteen of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This deficient practice had potential for patients prevented from reaching their care goals. --- 1.A review of Patient 1s ";Personal Information" sheet, indicated a start of care date on 5/9/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). During an interview on 12/14/2023, at 12:53 p.m., the Administrator/Director of Nurses (AD/DD) stated the validation that the IDG members attended the meeting was their signature. A record review of Patient 1s records indicated the following: ";POC/IDG", dated 11/29/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 11/15/2023, did not indicate the RN participated in the meeting and has no signature. ";POC/IDG", dated 11/1/2023, did not indicate the RN participated in the meeting and has no signature. ";POC/IDG", dated 10/18/2023, did not indicate the RN participated in the meeting and has no signature. ";POC/IDG", dated 10/4/2023, did not indicate the RN participated in the meeting and has no signature. 2. A review of Patient 2s ";Personal Information" sheet, indicated a start of care date on 4/7/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). A record review of Patient 2s records indicated the following: ";POC/IDG", dated 11/29/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 11/15/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 11/1/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 10/18/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 10/4/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. 3. A review of Patient 3s ";Personal Information" sheet, indicated a start of care date on 12/19/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). A record review of Patient 3s records indicated the following: ";POC/IDG", dated 11/29/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 11/15/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 11/1/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 10/18/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 10/4/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. 4. A review of Patient 4s ";Personal Information" sheet, indicated a start of care date on 10/19/2023, with a primary diagnosis of heart disease. A record review of Patient 4s records indicated the following: ";POC/IDG", dated 11/29/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 11/15/2023, did not indicate the RN participated in the meeting and has no signature. ";POC/IDG", dated 11/1/2023, did not indicate the RN participated in the meeting and has no signature. ";POC/IDG", dated 10/19/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. 5. A review of Patient 5s ";Personal Information" sheet, indicated a start of care date on 12/18/2020, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). A record review of Patient 5s records indicated the following: ";POC/IDG", dated 11/29/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 11/15/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 11/1/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 10/18/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. ";POC/IDG", dated 10/4/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. 6. A review of Patient 6s ";Personal Information" sheet, indicated a start of care date on 6/3/2021, with a primary diagnosis of heart disease. A record review of Patient 6s records indicated the following: ";POC/IDG", dated 3/21/2023, did not indicate the MSW participated in the meeting and has no signature. ";POC/IDG", dated 3/16/2023, did not indicate the MSW RN participated in the meeting and has no signature. ";POC/IDG", dated 3/2/2023, did not indicate the MSW, and RN participated in the meeting and has no signature. 7.A review of Patient 8s ";Patient Information" indicated Patient 8 start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s ";POC/IDG Review" dated 11/29/2023, indicated section ";MSW (medical social worker) Signature and RN (registered Nurse) Signatures were left blank. It also indicated Patient 8s language barrier was not addressed/documented. A review of Patient 8s ";POC/IDG Review" dated 11/15/2023, indicated section medical social worker (MSW) signature and Registered Nurse (RN) signatures were blank. It also indicated Patient 8s language barrier was not addressed/documented. A review of Patient 8s ";POC/IDG Review" dated 11/1/2023, indicated section ";MSW" signature and RN signatures were blank. It also indicated Patient 8s language barrier was not addressed/documented. A review of Patient 8s ";POC/IDG Review" dated 10/18/2023, indicated section ";MSW (medical social worker) Signature and RN (registered Nurse) Signatures were left blank. It also indicated Patient 8s language barrier was not addressed/documented. During a joint home visit 12/13/2023 at 10 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, greeted at door by Care Giver 1 (CG1). CG1 consented to visit. CG1 stated her preferred language was Spanish for both reading and speaking. CG1 stated in Spanish, that the HA staff knew she spoke Spanish and does not know why they provided all their paperwork in English. CG1 stated she would have requested the paperwork in Spanish, but she was not aware that there were provided in Spanish. LVN1 called Interpreter 1 (IP1) to assist with Spanish translation during home visit. 8.A review of Patient 9s ";Patient Information" indicated Patient 9 start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). A review of Patient 9s ";POC/IDG Review" dated 11/29/2023, indicated medical social worker (MSW) signature and Registered Nurse (RN) signatures were blank. A review of Patient 9s ";POC/IDG Review" dated 11/15/2023, indicated section ";RN" signatures was blank. A review of Patient 9s medical record form titled ";POC/IDG Review" dated 11/1/2023, indicated section ";RN" signatures was blank. A review of Patient 9s medical record form titled ";POC/IDG Review" dated 10/18/2023, indicated section ";RN" signatures was blank. 9.A review of Patient 10s ";Patient Information" indicated Patient 10 start of care date of 11/3/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 10s ";POC/IDG Review" dated 11/29/2023, indicated section medical social worker (MSW) signature and Registered Nurse (RN) signatures were blank. A review of Patient 10s ";POC/IDG Review" dated 11/15/2023, indicated section MSW signature and RN signatures were blank. A review of Patient 10s ";POC/IDG Review" dated 11/1/2023, indicated section MSW signature and RN signatures were blank. A review of Patient 10s ";POC/IDG Review" dated 10/18/2023, indicated section MSW signature and RN signatures were blank. 10.A review of Patient 11s ";Patient Information" indicated Patient 11 start of care date of 10/20/2023, with diagnoses including cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). A review of Patient 11s ";POC Summary" dated as of 12/12/2023, indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." A review of Patient 11s ";POC/IDG Review" dated 11/29/2023, indicated section medical social worker (MSW) signature and Registered Nurse (RN) signatures were blank. A review of Patient 11s ";POC/IDG Review" dated 11/15/2023, indicated section ";MSW" signature and RN signatures were blank. A review of Patient 11s ";POC/IDG Review" dated 11/1/2023, indicated section ";MSW" signature and RN signatures were blank. 11.A review of Patient 12s ";Patient Information" indicated Patient 12 start of care date of 1/13/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 12s ";POC/IDG Review" dated 11/29/2023, indicated section medical social worker (MSW) signature and Registered Nurse (RN) signatures were blank. A review of Patient 12s ";POC/IDG Review" dated 11/15/2023, indicated section MSW signature and RN signatures were blank. A review of Patient 12s ";POC/IDG Review" dated 11/1/2023, indicated section ";MSW (medical social worker) signature and RN signatures were blank. A review of Patient 12s ";POC/IDG Review" dated 10/18/2023, indicated section ";MSW (medical social worker) signature and RN signatures were blank. 12.A review of Patient 13s ";Patient Information" indicated Patient 13 start of care date of 4/1/2021, with diagnoses including malignant neoplasm (cancer) of prostate. A review of Patient 13s ";POC/IDG Review" dated 6/22/2023, indicated section ";MSW (medical social worker) signature was blank. A review of Patient 13s ";POC/IDG Review" dated 6/8/2023, indicated section ";MSW (medical social worker) signature was blank. A review of Patient 13s ";POC/IDG Review" dated 5/25/2023, indicated section ";MSW (medical social worker) signature was blank. 13.A review of Patient 14s ";Patient Information" indicated Patient 14 start of care date of 7/20/2023, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 14s ";POC Summary" dated as of 12/12/2023, indicated ";IDG to review patients status every 14 days and as needed to evaluate changes in condition." A review of Patient 14s ";POC/IDG Review" dated 9/9/2023, indicated section ";MSW (medical social worker) signature was blank. A review of Patient 14s ";POC/IDG Review" dated 9/6/2023, indicated section ";MSW (medical social worker) signature was blank. A review of Patient 14s ";POC/IDG Review" dated 8/23/2023, indicated section ";MSW (medical social worker) signature was blank. During an interview on 12/14/2023 at 12:45 p.m. with the Administrator/Director of Nurses Designee (AD/DD), AD/DD stated IDG members were the admitting nurse, social worker, chaplain, and medical director. AD/DD stated IDG meetings are held every two weeks for all patients to make sure there were no changes, declines, or new orders. AD/DD stated disciplines present need to provide their electronic signature as proof that they attended the meetings. AD/DD stated the last HA IDG meeting was held on 11/28/2023 or 11/20/2023. AD/DD stated her employment at the HA started on 12/1/2023, and that is why she was unsure of the last IDG meeting. On 12/15/2023 at 10:42 a.m. Medical Social Worker 1 (MSW1) was called, with no answer. Message with call back number left. During a telephone interview on at 10:43 a.m. with Medical Social Worker 2 (MSW2), MSW2 stated she assist patient and their families with resources, emotional support, paperwork, Medicate, and her main job is to provide support and listen to them vent out their feelings and concerns. MSW2 stated she has five days to complete and document patient recertification assessments. A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" dated 2019, indicated: ";Procedure...Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently than every 15 days or more frequently if the patients condition requires...A plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment." A record review of the HAs policy and procedure titled, ";Comprehensive Assessment", dated 2019, indicated, ";Procedure...5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days." A record review of the HAs policy and procedure titled, ";Ongoing Comprehensive Assessment" dated 2019, indicated ";Procedure: 1. During each home visit, the Case Manager or the other discipline will evaluate the patient according to the problems identified... The scope and intensity of ongoing hospice patient assessment will be determined by the patients prognosis, diagnosis, condition...Based on the assessments, the plan of care – including problems, needs, goals, and outcomes – will be reviewed and updated by the interdisciplinary group members responsible for the care." A record review of the HAs policy and procedure titled, ";The Plan of Care", dated 2019, indicated ";The written plan of care will contain, but will not be limited to, the following: frequency of services... interdisciplinary group assessment of needs..."

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 meet the Condition of Participation for Interdisciplinary group, care planning, and coordination of services as follows: --- 1. The HA failed to follow the Plan of Care (POC, maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver) for one of 14 sampled patients (Patient 8). (Refer to L543). 2. The HA failed to provide education based on their plan of care for one of fourteen sample patients (Patient 8) (Refer to L544). 3. The HA failed to develop an individualized plan of care (POC) for one of fourteen sample patients (Patient 8) that included specific care needed for respiratory status. (Refer to L545). 4. The HA failed for 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), reviewed and revised the plan of care (POC- an individualized care planned) for three of 14 sampled patients (Patient 4, Patient 8 and Patient 9) (Refer to L552). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with Federal regulations for Interdisciplinary group, care planning, and coordination of services.

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 to follow Plan of Care (POC – individualized care planned) for one of 14 sampled patients (Patient 8). This deficient practice resulted in hospice care and services not provided to meet Patient 8's care goal needs. --- A review of Patient 8s ";Patient Information" indicated Patient 8 start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s ";POC Summary" dated as of 12/12/2023, indicated ";Skilled Nurse (SN) to visit once a week to assess all systems and evaluate patients care needs." It also indicated ";Skilled Nurse to perform/train Patient/PCG (Patient Care Giver) re: altered mental status, severe shortness of breath, chest pain, fall, injury and other abnormal findings." A review of Patient 8s ";POC/IDG Review" dated 11/29/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Endocrine – Goal: maintained fasting blood glucose levels between 70 to 100 mmHg by next recertification. Interventions: monito/assess effectiveness of current medication/treatment. Metformin (high blood sugar medication) 500 milligrams twice a day. Gastro-Intestinal – Interventions: Assess/monitor nutritional needs every visit. Ongoing assessment of intake, indigestion, food preference and weight change. During a joint home visit on 12/13/2023 at 10 a.m. with License Vocational Nurse 1 (LVN1) at Patient 8s home and an interview with Patient 8s Care Giver (CG1), CG1 stated Patient 8 was diagnosed with diabetes (high blood sugar) about ten years ago and has been taking medications for it since. CG1 stated Patient 8 was using his oxygen a lot of last week because he was getting over a cold. CG1 stated HA Interpreter (IP1) was at their home 10 minutes prior to our arrival and instructed her to place a no smoking sign outside Patient 8s bedroom. During an interview on 12/13/2023 at 11:20 a.m. with License Vocational Nurse 1 (LVN1), LVN1 stated she did not have Patient 8s POC or medication list. LVN1 stated Patient 8's POC was needed to be able to follow the treatment plan. LVN1 stated Patient 8s diagnoses included Alzheimers Disease and diabetes (high blood sugar). LVN1 stated Patient 8 has not used oxygen. LVN1 stated she did not ask Patient 8 or his CG1 about his blood sugar readings, his oxygen use, about his diabetic diet, changes in mental status, shortness of breath, chest pain, fall, injuries, or about his weight. LVN1 stated she did not take Patient 8s MAC (Mid Arm Circumference) measurement. LVN1 stated she was supposed to ask about his blood sugar readings because both low and high levels can cause Patient 8 to go into a coma. A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" dated 2019, indicated ";Policy...Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires." A record review of the HAs policy and procedure titled, ";Initial Assessment", dated 2019, indicated ";Procedure...7. Based on the initial assessments, the plan of care will be initiated on the day of admission." A record review of the HAs policy and procedure titled, ";The Plan of Care", dated 2019, indicated ";Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. Procedure...1. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care...The plan of care will be reviewed prior to care being delivered."

7 Days Hospice Care Tag – L0544 Event ID: 61B86-HI Deficient Practice Statement Barbra DeLaTorre | Last Updated 12/26/2023 3:43 PM Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure one of fourteen sample patients (Patient 8) receive education based on their plan of care. This failure had the potential to result in patient and/or caregiver does not know what or how to complete a task to assist the patient during their dying process. Delia Zamora's Findings Writing Complete | Last Updated by Delia Zamora 12/26/2023 4:39 PM DeleteDelia Zamora's Findings A review of Patient 8s medical record form titled ";Patient Information" indicated Patient 8 start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s medical record form titled ";POC/IDG Review" dated 11/29/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Endocrine – Goal: maintained fasting blood glucose levels between 70 to 100 mmHg by next recertification. Interventions: monito/assess effectiveness of current medication/treatment. Metformin (high blood sugar medication) 500 milligrams twice a day. During a joint home visit on 12/13/2023 at 10 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, Patient 8s Care Giver (CG1) stated Patient 8 was diagnosed with diabetes (high blood sugar) about ten years ago and has been taking medications for it since. CG1 stated Patient 8 was using his oxygen a lot of last week because he was getting over a cold. CG1 stated HA Interpreter (IP1) was at their home 10 minutes prior to our arrival and instructed her to place a no smoking sign outside Patient 8s bedroom. During an interview on 12/13/2023 at 11:20 a.m. with License Vocational Nurse 1 (LVN1), LVN1 stated she did not have Patient 8s POC or medication list. LVN1 stated a patients POC is needed to be able to follow their treatment plan. LVN1 stated Patient 8s diagnoses included Alzheimers Disease and diabetes (high blood sugar). LVN1 stated Patient 8 has not used oxygen. LVN1 stated she did not ask Patient 8 or his CG1 about his blood sugar readings or his oxygen use. LVN1 stated she was supposed to ask about his blood sugar readings because both low and high levels can cause Patient 8 to go into a coma. LVN1 stated she did not provide Patient 8 or CG1 education on diabetes or oxygen use. The HA failed to provide Patient 8 and CG1 oxygen use and diabetes education. A review of facilitys public brochure, undated, indicated ";The nurse also teaches the family and/or other caregivers how to care for the patient." A review of facility form titled ";Job Title/Position: License Practical/Vocational Nurse" undated, indicated ";Assesses and provide patient and family/caregiver education and information pertinent to diagnosis and self-plan of care." Writing Complete | Last Updated by Delia Zamora 12/26/2023 4:39 PM DeleteDelia Zamora's Findings A review of Patient 8s medical record form titled ";Patient Information" indicated Patient 8 start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s medical record form titled ";POC/IDG Review" dated 11/29/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Endocrine – Goal: maintained fasting blood glucose levels between 70 to 100 mmHg by next recertification. Interventions: monito/assess effectiveness of current medication/treatment. Metformin (high blood sugar medication) 500 milligrams twice a day. During a joint home visit on 12/13/2023 at 10 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, Patient 8s Care Giver (CG1) stated Patient 8 was diagnosed with diabetes (high blood sugar) about ten years ago and has been taking medications for it since. CG1 stated Patient 8 was using his oxygen a lot of last week because he was getting over a cold. CG1 stated HA Interpreter (IP1) was at their home 10 minutes prior to our arrival and instructed her to place a no smoking sign outside Patient 8s bedroom. During an interview on 12/13/2023 at 11:20 a.m. with License Vocational Nurse 1 (LVN1), LVN1 stated she did not have Patient 8s POC or medication list. LVN1 stated a patients POC is needed to be able to follow their treatment plan. LVN1 stated Patient 8s diagnoses included Alzheimers Disease and diabetes (high blood sugar). LVN1 stated Patient 8 has not used oxygen. LVN1 stated she did not ask Patient 8 or his CG1 about his blood sugar readings or his oxygen use. LVN1 stated she was supposed to ask about his blood sugar readings because both low and high levels can cause Patient 8 to go into a coma. LVN1 stated she did not provide Patient 8 or CG1 education on diabetes or oxygen use. The HA failed to provide Patient 8 and CG1 oxygen use and diabetes education. A review of facilitys public brochure, undated, indicated ";The nurse also teaches the family and/or other caregivers how to care for the patient." A review of facility form titled ";Job Title/Position: License Practical/Vocational Nurse" undated, indicated ";Assesses and provide patient and family/caregiver education and information pertinent to diagnosis and self-plan of care."

Based on interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to develop an individualized plan of care (POC) that reflect the patient's current health status for one of 14 sampled patients (Patient 8). This deficient practice had the potential for delay or lack of care to meet the patient's care goals. --- A review of Patient 8s ";Patient Information" indicated Patient 8 start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s ";Comprehensive Nursing Assessment" dated 7/15/2022, indicated ";Teaching Needs – Oxygen". A review of Patient 8s ";Re-Cert Assessment" dated 12/11/2023, indicated ";Teaching Needs – Oxygen". A review of Patient 8s ";POC Summary" dated as of 12/12/2023, indicated ";Skilled Nurse (SN) to visit once a week to assess all systems and evaluate patients care needs." It also indicated ";Skilled Nurse to perform/train Patient/PCG (Patient Care Giver) re: severe shortness of breath..." A review of Patient 8s ";POC/IDG Review" dated 11/29/2023, indicated there was no care planned or documentation of Patient 8s respiratory system. During a joint home visit on 12/13/2023 at 10 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, Patient 8s Care Giver (CG1) stated Patient 8 was using his oxygen a lot of last week because he was getting over a cold. CG1 stated HA Interpreter (IP1) was at their home 10 minutes prior to our arrival and instructed her to place a no smoking sign outside Patient 8s bedroom. During an interview on 12/13/2023 at 11:20 a.m. with License Vocational Nurse 1 (LVN1), LVN1 stated she did not have Patient 8s POC. LVN1 stated Patient 8 needed POC to be able to follow their treatment plan. LVN1 stated she was not aware Patient 8 used oxygen. LVN1 stated she did not ask Patient 8 or his CG1 about his oxygen use. A review of facilitys public brochure, undated, indicated ";The PCM (Patient Care Manager) is a registered nurse who is responsible for the management and coordinator of care... He/she makes certain that the plan of care for each patient is unique, individualized, and interdisciplinary." A review of facility form titled ";Job Title/Position: License Practical/Vocational Nurse" undated, indicated ";Assesses and provide patient and family/caregiver education and information pertinent to diagnosis and self-plan of care."

Based on interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) reviewed and revised the plan of care (POC) for three of 14 sampled patients (Patient 4, Patient 8, and Patient 9). This deficient practice had the potential for harm if patients are prevented from reaching their goals, due to IDG not addressing changes in the patient's condition. --- 1.A review of Patient 4s ";Personal Information" sheet, indicated a start of care date on 10/19/2023, with a primary diagnosis of heart disease. During an interview on 12/14/2023, at 9:35 a.m., Patient 4 stated she needed help at home with housekeeping and meal preparation because she had hurt her right hand from a fall. Patient 4 stated she informed the HA four weeks prior. During a concurrent interview and record review on 12/14/2023, at 1:50 p.m., the Administrator/Director of Nurses designee (AD/DD) reviewed Patient 4s record titled, ";POC/IDG Review", dated 11/1/2023. The record indicated, Medical Social Worker (MSW) provided emotional support and offered referrals to various community resources including support group and individual counseling services, private duty caregiver resources...". The AD/DD stated, ";When we provide CHHA (Certified Home Health Aide) services, they can do light housekeeping. If the patients want more help that is why we refer them to private companies. When you ask patients about their care, they tend to complain more. Im not saying her complaint is not valid, but it sounds like what she is looking for is IHHS (in home health support), we dont provide that. Yes, the social worker can help her with that." The AD/DD stated there was no documentation about the follow up to see if the referrals were effective. The social worker was supposed to follow up to see if her needs were met with the referrals. There was no follow up documentation. The AD/DD stated the HA did not know if Patient 4s needs were met. 2.A review of Patient 8s ";Patient Information" indicated Patient 8 start of care date of 7/15/2022, with diagnoses including Alzheimers disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s ";POC/IDG Review" dated 11/29/2023, 11/15/2023, 11/1/2023, and 10/18/2023, indicated sections ";medical social worker (MSW) signature and Registered Nurse (RN) signatures were blank. It also indicated Patient 8s language barrier was not addressed/documented and has no care planned or documentation of Patient 8s respiratory system. A review of Patient 8s ";POC Summary" dated as of 12/12/2023, indicated ";Tylenol liquid (pain/fever reducer medication), Seroquel (agitation medication), Ferrous Sulfate (iron supplement), Refresh eye drops, Acetaminophen (pain/fever reducer medication), Diclofenac Sodium 1% topical gel (pain medication), Zyrtec (allergy medication), and Duoneb (congestion medication)" were listed on the form. It also indicated ";Skilled Nurse (SN) to visit once a week to assess all systems and evaluate patients care needs." It also indicated ";Skilled Nurse to perform/train Patient/PCG (Patient Care Giver) re: severe shortness of breath..." A review of Patient 8s ";Comprehensive Nursing Assessment" dated 7/15/2022, indicated ";Teaching Needs – Oxygen". A review of Patient 8s ";Re-Cert Assessment" dated 12/11/2023, indicated ";Teaching Needs – Oxygen". During a joint home visit on 12/13/2023 at 10 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, Patient 8s Caregiver (CG1) stated Patient 8 was using his oxygen a lot of last week because he was getting over a cold. CG1 stated HA Interpreter (IP1) was at their home 10 minutes prior to our arrival and instructed her to place a no smoking sign outside Patient 8s bedroom. LVN1 requested Patient 8s Care Giver 1 (CG1) to provide all of Patient 8s medications. CG1 provided medications and stated she provides all the medication Patient 8 takes. CG1 stated Patient 8 was not currently taking the medication listed on the POC Summary: Tylenol liquid, Seroquel, Ferrous Sulfate, Refresh eye drops, Acetaminophen, Diclofenac Sodium 1% topical gel, Zyrtec, and Duoneb. CG1 stated her preferred language was Spanish for both reading and speaking. CG1 stated in Spanish, that the HA staff knew she spoke Spanish and does not know why they provided all their paperwork in English. CG1 stated she would have requested the paperwork in Spanish, but she was not aware that there were provided in Spanish. LVN1 called Interpreter 1 (IP1) to assist with Spanish translation during home visit. During an interview on 12/13/2023 at 11:20 a.m. with License Vocational Nurse 1 (LVN1), LVN1 stated she did not have Patient 8s POC and medication list. LVN1 stated a patients POC is needed to be able to follow their treatment plan. LVN1 stated she was not aware Patient 8 used oxygen. LVN1 stated she did not ask Patient 8 or his CG1 about his oxygen use or completed Patient 8s medication reconciliation. 3.A review of Patient 9s ";Patient Information" indicated Patient 9 start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). A review of Patient 9s ";POC/IDG Review" dated 11/29/2023, 11/15/2023, 11/1/2023, and 10/18/2023, indicated section ";Registered Nurse (RN) signatures was blank. A review of Patient 9s ";POC Summary" dated as of 12/12/2023, indicated ";Isosorbide Mononitrate (chest pain medication), Nitroglycerine 0.3mg (chest pain medication), Vitamin D (supplement), Maxitrol (anti-infective medication), Cefdinir (anti-infective medication), Escitalopram (depression medication)." During a joint home visit on 12/13/2023 at 11:45 a.m. with License Vocational Nurse 1 (LVN1) to Patient 9s home, LVN1 requested Patient 9s Caregiver 2 (CG2) to provide all of Patient 9s medications. CG2 stated Patient 9 did not take some of the medications listed Patient 9s POC Summary dated as of 12/12/2023: 1. Maxitrol every 6 hours x7 days for infection ordered date 6/18/2023 CG2 stated Patient 9 has not used since January 2023 2. Cefdinir twice daily for 7 days CG2 stated Patient 9 has not used since January 2023 3. Escitalopram once daily CG2 stated last time Patient 9 took was in March 2023, stated she does not need the medication because she is not depressed. CG2 stated Patient 9s UTI (urinary tract infection) and eye infections were cleared in January 2023. During an interview on 12/14/2023 at 12:45 p.m. with the Administrator/Director of Nurses Designee (AD/DD), AD/DD stated IDG members were the admitting nurse, social worker, chaplain, and medical director. AD/DD stated IDG meetings are held every two weeks for all patients to make sure there were no changes, declines, or new orders. AD/DD stated disciplines present need to provide their electronic signature as proof that they attended the meetings. AD/DD stated the last HA IDG meeting was held on 11/28/2023 or 11/20/2023. AD/DD stated her employment at the HA started on 12/1/2023, and that is why she was unsure of the last IDG meeting. A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" dated 2019, indicated ";Policy...Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires."

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 governing body met to approve their quality assurance and performance improvement (QAPI, a data driven and proactive approach to quality improvement) program on a quarterly basis. This deficient practice had the potential to result in patients receiving poor quality of care and services. --- During an interview on 12/15/2023 at 12:15 p.m. with the Administrator/Director of Nurses Designee (AD/DD), AD/DD was requested to provide governing body minutes. AD/DD stated she was new and does not know where they were. A review of facility form titled ";Job Title/Position: Secretary/Receptionist" undated, indicated ";Maintains minutes of meetings." A review of facility form titled ";Employee List" undated, indicated the Administrator/Director of Nurses (ADM/DON), was not listed on the HA employee list. A review of the Administrator/Director of Nurses Designee (AD/DD) HA employment application dated 12/1/2023, indicated AD/DD signed and dated form on 12/1/2023. A review of facility form titled ";Job Title/Position: Executive Director/Administrator (Alternate)" undated, indicated ";Assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessmen5t and performance improvement. A qualified administrator appointed by and reporting to the governing body is responsible for the day-today operations of the hospice." It also indicated it was signed by AD/DD on 12/1/2023. A review of facility form titled ";Job Title/Position: Clinical Director/Director of Patient Care Services (Alternate)" undated, indicated ";The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements, and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy." It also indicated it was signed by AD/DD on 12/1/2023.

Based on interview and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for Core Services as follows: --- 1. The HA failed to ensure seven of fourteen sampled patients (Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) received psychological assessment as ordered on their plan of care. (Refer to L594). 2. The HA failed to provide bereavement services to two of fourteen sampled patients (Patient 7 and Patient 14). (Refer to L596). 3. The HA failed to ensure six of fourteen sampled patients (Patient 7, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 14) received initial spiritual counseling services to meet their spiritual needs. (Refer to L598). These deficient practices resulted in the HA not providing the core services/care as required and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life.

Based on interview and record review, the Hospice Agency (HA) failed to ensure seven of fourteen sampled patients (Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) received psychological assessment as ordered in their plan of care. This failure had the potential to result in patient and caregiver/family not receiving assessment and support of their needs. --- a. A review of Patient 7s ";Personal Information" sheet, indicated a start of care date of 9/14/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). The record further indicated an end of care date of 9/16/2023, due to death. During a concurrent interview and record review on 12/15/2023, at 11:25 a.m., the Administrator/Director of Nurses Designee (AD/DD) reviewed Patient 7s clinical records. The AD/DD stated a psychosocial assessment had not been done for Patient 7 and did not know why it was not done. The AD/DD stated the assessment was supposed to be done within a few days by the social worker. The AD/DD stated the assessment is important because it is part of the plan of care. The HA has to know what needs Patient 7 has. The HA did not know the needs because the psychosocial assessment was not done. b. A review of Patient 8s medical record form titled ";Patient Information" sheet, indicated Patient 8 had start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (a progressive memory loss) and atherosclerotic heart disease of native coronary artery (a plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s medical record form titled ";Comprehensive Nursing Assessment" dated 7/15/2022, indicated Social Worker (SW), Spiritual Counselor (SC), and Bereavement Counselor (BC) visits were needed. A review of Patient 8s medical record form titled ";POC Summary" dated 12/12/2023, indicated ";Medical Social Worker contact once every month..." A review of Patient 8s medical record form titled ";POC/IDG Review" dated 7/15/2022, indicated section ";Medical Social Worker (MSW) Signature was left blank. The record also indicated Patient 8s language barrier was not addressed/documented. A review of Patient 8s medical record form titled ";Psychosocial Assessment" dated 11/7/2023, indicated the form was blank. The form also indicated there was no HA staff signature. During a concurrent interview and record review on 12/14/2023 at 1:30 p.m. with the AD/DD of Patient 8s Electronic Medical Record (EMR), AD/DD stated Patient 8s psychosocial assessment dated 11/7/2023 was blank except for the narrative section. AD/DD stated the form was not signed and did not know who completed the narrative section. AD/DD stated the last time MSW saw Patient 8 was on 9/8/2023 but signed the assessment note on 11/15/2023. c. A review of Patient 10s medical record form titled ";Patient Information" sheet, indicated Patient 10 had a start of care date of 11/3/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 10s medical record form titled ";Comprehensive Nursing Assessment" dated 11/3/2021, indicated SW (Social Worker), SC (Spiritual Counselor), and BC (Bereavement Counselor) visits were needed. A review of Patient 10s medical record form titled ";POC Summary" dated 12/12/2023, indicated ";Medical Social Worker contact once every recertification..." A review of Patient 10s medical record form titled ";Psychosocial Assessment" dated 11/4/2021, indicated form was blank. The record also indicated there was no HA staff signature. d. A review of Patient 11s medical record form titled ";Patient Information" sheet, indicated Patient 11 had a start of care date of 10/20/2023, with diagnoses including cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). A review of Patient 11s medical record form titled ";Comprehensive Nursing Assessment" dated 10/20/2023, indicated SW (Social worker), SC (Spiritual Counselor), and BC (Bereavement Counselor) visits were needed. A review of Patient 11s medical record form titled ";POC Summary" dated 12/12/2023, indicated ";Medical Social Worker once per recertification..." A review of Patient 11s medical record form titled ";POC/IDG Review" dated 10/20/2023, indicated section ";MSW (Medical Social Worker) Signature and RN (Registered Nurse) Signature were left blank. A review of Patient 11s medical record form titled ";Psychosocial Assessment" dated 10/21/2023, indicated there was no HA staff signature. e. A review of Patient 12s medical record form titled ";Patient Information" sheet, indicated Patient 12 had a start of care date of 1/13/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 12s medical record form titled ";Comprehensive Nursing Assessment" dated 1/13/2021, indicated SW (Social worker), SC (Spiritual Counselor), and BC (Bereavement Counselor) visits were needed. A review of Patient 12s medical record form titled ";POC Summary" dated 12/12/2023, indicated ";Medical Social Worker contact once every recertification..." A review of Patient 12s medical record form titled ";Psychosocial Assessment" dated 1/16/2021, indicated form was blank. The record also indicated there was no HA staff signature. A review of Patient 12s medical record form titled ";Communication Log" dated 10/6/2020 to 12/12/2023, indicated there were no communications logged. f. A review of Patient 13s medical record form titled ";Patient Information" sheet, indicated Patient 13 had a start of care date of 4/1/2021, with diagnoses including malignant neoplasm (cancer) of prostate. A review of Patient 13s medical record form titled ";Comprehensive Nursing Assessment" dated 4/1/2023, indicated SW (Social worker), SC (Spiritual Counselor), and BC (Bereavement Counselor) visits were needed. A review of Patient 13s medical record form titled ";POC/IDG Review" dated 4/1/2023, indicated section ";MSW (Medical Social Worker) Signature was left blank. A review of Patient 13s medical record form titled ";POC Summary" dated 12/12/2023, indicated ";Medical Social Worker contact once every recertification..." A review of Patient 13s medical record form titled ";Psychosocial Assessment" dated 4/1/2023, indicated form was blank. The record also indicated there was no HA staff signature. A review of Patient 13s medical record form titled ";Communication Log" dated 4/1/2023 to 12/12/2023, indicated there were no communications logged. g. A review of Patient 14s medical record form titled ";Patient Information" sheet, indicated Patient 14 had a start of care date of 7/20/2023, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 14s medical record form titled ";POC/IDG Review" dated 7/20/2023, indicated section ";MSW (Medical Social Worker) Signature was left blank. A review of Patient 14s medical record form titled ";POC Summary" dated 12/12/2023, indicated ";Medical Social Worker contact once a month..." A review of Patient 14s undated medical record form titled ";History of Psychosocial Assessment", indicated there were no psychosocial assessments documented. During an interview on 12/14/2023 at 12:15 p.m. with the AD/DD, AD/DD stated the Medical Social Worker (MSW) is required to complete patients initial assessment within five days of admission. AD/DD stated if a patient refuses MSW services, the MSW needs to document in the patients medical record their refusal and continue to offer their services monthly. A review of facility policy and procedure titled ";Psychosocial Services" revised 4/2019, indicated ";(HA) will provide psychosocial services by qualified social workers (MSW, BSW) under the direction of a physician and in accordance with the plan of care. Psychosocial services will include: assessing emotional factors related to terminal illness; patient and family/caregiver counseling around issues of death, dying, and grief...Assessment activities of the social worker will include but not be limited to: Bereavement needs."

Based on interview and record review, the Hospice Agency (HA) failed to ensure two of fourteen sampled patients' (Patient 7 and Patient14) families had bereavement counseling postmortem. This failure resulted in families/care givers did not receive the bereavement services after their family member passed away. --- a. A review of Patient 7s ";Personal Information" sheet, indicated a start of care date of 9/14/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). The record further indicated an end of care date of 9/16/2023, due to death. During a concurrent interview and record review on 12/15/2023, at 11:28 a.m., the Administrator/Director of Nurses designee (AD/DD) reviewed Patient 7s clinical records. The AD/DD stated there was no bereavement plan of care and did not know why. When asked about the importance of a bereavement plan of care, the AD/DD stated, ";So we know we provided the service. We have to document everything. Nurse has to notify the doctor, notify mortuary (a funeral home or morgue), dispose medication, prepare the body, and provide support to the family. All this should be in the bereavement POC (plan of care)." During a concurrent interview and record review on 12/15/2023, at 11:32 a.m., the AD/DD reviewed Patient 7s clinical records. The AD/DD stated there was no post death bereavement assessment and did not know why it had not done. The AD/DD stated the purpose of the assessment was to make sure all the services were provided: notification of doctor, notifying mortuary, assessing family support, and making sure Medical Social Worker (MSW) and Spiritual Counselor (SC) are available to the patient, so we continue to provide services to the family. During a concurrent interview and record review on 12/15/2023, at 11:34 a.m., the AD/DD reviewed Patient 7s clinical records. The AD/DD stated there was no indication if letters were sent to the caregiver/family and did not know why. The AD/DD stated the office staff was supposed to provide them at one month, three months, six months, and yearly. The AD/DD stated the purpose of the letters is part of the plan of care to follow up and to let them know someone cares about them. b. A review of Patient 14s medical record form titled ";Patient Information" sheet, indicated Patient 14 had a start of care date of 7/20/2023 and end of care date of 9/9/2023, due to death. The record indicated Patient 14s diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 14s medical record form titled ";POC Summary" dated 12/12/2023, indicated ";Initial bereavement assessment completed with primary bereaved, bereavement risk is low." A review of Patient 14s undated medical record form titled ";History of Psychosocial Assessment", indicated there were no psychosocial assessments documented. A review of Patient 14s medical record form titled ";Spiritual Assessment" dated 7/22/2023, indicated ";I placed a phone call to patients primary caregiver (PCG) to schedule appointment for visit and re-explained to caregiver (CG) again, my role in the hospice circle of care, and services available to them. Currently, the patients CG, wishes to refuse spiritual services at this time..." The record also indicated it was signed by the Spiritual Counselor (SC). A review of Patient 14s medical record form titled ";Discharge Summary" dated 9/9/2023, indicated ";Referral was made to bereavement coordinator to provide assessment and post-death services." The record also indicated it was signed by the Registered Nurse 1 (RN1). A review of Patient 14s undated medical record form titled ";History of Post - Death Bereavement Assessment", indicated there were no psychosocial assessments documented. A review of Patient 14s undated medical record form titled ";History of Bereavement Letters", indicated there were no psychosocial assessments documented. A review of Patient 14s undated medical record form titled ";Post - Death Bereavement Support", indicated form was blank. The record also indicated bereavement letters were overdue. During a concurrent interview and record review on 12/15/2023 at 12:40 p.m. with the AD/DD of Patient 14s medical record, AD/DD stated Patient 14 end of care date was on 9/9/2023 due to death. AD/DD stated Patient 14s did not have a bereavement assessment, including a post bereavement assessment. AD/DD stated the social worker had a responsibility to call Patient 14s family after her death. AD/DD stated social services had to be involved to provide support to the family and to assess if additional support was needed. A review of facilitys public brochure, undated, indicated ";The Hospice Bereavement Coordinator works with the family and develops a plan to support and help them during their time of loss. The Bereavement Coordinator is a specialist who is aware of the difficulties and needs of a family as they go through this time of loss. Social work and chaplain visits to assist with final arrangements and bereavement care afterwards." A review of facility policy and procedure titled ";Psychosocial Services" revised 4/2019, indicated ";(HA) will provide psychosocial services by qualified social workers (MSW, BSW) under the direction of a physician and in accordance with the plan of care. Psychosocial services will include: assessing emotional factors related to terminal illness; patient and family/caregiver counseling around issues of death, dying, and grief...Assessment activities of the social worker will include but not be limited to: Bereavement needs." A review of facility policy and procedure titled ";Bereavement Services" revised 4/2019, indicated ";(HA) will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one (1) year following the death of the patient. The program will provide bereavement services to the families/caregivers of hospice patients both before and after the patients death in accordance with the plan of care. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. A plan will be developed to address bereavement/grief issues and will be implemented as needed. After death has occurred, the bereavement assessment will be updated, and the family/caregiver will be discussed at the next interdisciplinary group meeting."

Based on interview and record review, the Hospice Agency (HA) failed to ensure two of fourteen sampled patients (Patient 7 and Patient 12) received spiritual counseling services to meet their spiritual needs. This failure had the potential to result in not providing patients and their caregivers the spiritual assistance to provide comfort in the dying process. --- a. A review of Patient 7s ";Personal Information" sheet, indicated a start of care date of 9/14/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). The record further indicated an end of care date of 9/16/2023, due to death. During a concurrent interview and record review on 12/15/2023, at 11:25 a.m., the Administrator/Director of Nurses Designee (AD/DD) reviewed Patient 7s clinical records. The AD/DD stated a spiritual assessment had not been done for Patient 7 and did not know why it was not done. b.A review of Patient 12s medical record form titled ";Patient Information" sheet, indicated Patient 12 had start of care date of 1/13/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 12s medical record form titled ";Comprehensive Nursing Assessment" dated 1/13/2021, indicated SW (Social Worker), SC (spiritual Counselor), and BC (Bereavement Counselor) visits were needed. A review of Patient 12s medical record form titled ";POC Summary" dated 12/12/2023, indicated ";Spiritual services offered but declined, for 90 days." A review of Patient 12s medical record form titled ";Spiritual Assessment" dated 1/14/2021, indicated ";I placed a phone call to patients PCG to schedule appointment for visit and re-explained to CG again, my role in the hospice circle of care, and services available to them. Currently, the patients CG, wishes to refuse spiritual services at this time..." The form also indicated it was signed by Spiritual Counselor (SC). A review of Patient 12s medical record form titled ";Spiritual Assessment" dated 9/1/2023, indicated ";I placed a phone call to patients PCG to schedule appointment for visit and re-explained to CG again, my role in the hospice circle of care, and services available to them. Currently, the patients CG, wishes to refuse spiritual services at this time..." The form also indicated it was signed by Spiritual Counselor (SC). A review of Patient 12s medical record form titled ";Communication Log" dated 10/6/2020 to 12/12/2023, indicated there were no communications logged. During a telephone interview on 12/15/2023 at 11:25 a.m. with SC, SC stated her responsibilities were to provide spiritual and emotional support. SC stated, "My responsibility is to provide spiritual and emotional support to our patients, to call, visit, pray, and support the family as well in their grief." SC stated, ";I call the family and ask them if they want my visit. I go within five days. I put my first assessment note within five days of admission as a visit or phone call. If patient refuse SC services, I follow up the next month as ask them if they want my services. I document that they dont want my services, in the visit notes." A review of facility policy and procedure titled ";Spiritual Care Counseling Services" revised 4/2019, indicated ";(HA) will provide spiritual care counseling in keeping with the patient/family/caregiver belief system and practice, and in accordance with the plan of care." The policy and procedure indicated if the patient and family/caregiver refuses spiritual care services, the medical social worker will document refusal. The interdisciplinary group members will make continued inquires as appropriate. The policy and procedure further indicated that all referrals, assessments, clinical notes, intervention letters and phone calls will be documented in the patient's clinical record.

Based on interview and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for Interdisciplinary group, care planning, and coordination of services as follows: --- 1. The HA failed to ensure the Certified Home Health Aide 1 (CHHA1) had the qualifications to be able to take care one of fourteen sampled patients (Patient 8) by not providing CHHA1 employee record or documentation to verify his education and/or training. (Refer to L614). 2. The HA failed to ensure the Certified Home Health Aide 1 (CHHA1) was competent to be able to take care for one of fourteen sampled patients (Patient 8) by not providing CHHA1 employee record or documentation to verify his competency, education and/or training. (Refer to L619). 3. The HA failed to ensure Certified Home Health Aide 1 (CHHA1) followed two of fourteen sampled patients' (Patient 8 and Patient 12) CHHA plan of care (individualized care plan) by not assessing patient's vital signs. (Refer to L626). 4. The HA failed to ensure a Registered Nurse (RN) conducted Certified Home Health Aide supervisory visits every 14 days for one of fourteen sampled patients (Patient 8). (Refer to L629). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with Federal regulations for Interdisciplinary group, care planning, and coordination of services.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Certified Home Health Aide 1 (CHHA1) had the qualifications to be able to take care one of fourteen sampled patients (Patient 8) by not providing CHHA1 employee record or documentation to verify his education and/or training. This failure had the potential to result in Patient 8 being taken care of by unqualified personnel, which had the potential to result in injury, harm, or death. --- A review of Patient 8s medical record form titled ";Patient Information" sheet, indicated Patient 8 had a start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s medical record form titled ";POC Summary" dated 12/12/2023, indicated ";CHHA services once a week for ADLs (activities of daily living) and Hygiene." A review of Patient 8s medical record form titled ";HA Assignment" dated 1/16/2023, indicated it was signed by Registered Nurse 1 (RN1). A review of Patient 8s medical record form titled ";HA Visit Note" dated 11/30/2023 and 12/5/2023, indicated both forms were signed by CHHA1. During a joint home visit on 12/13/2023 at 10:00 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, greeted at door by Caregiver (CG1). CG1 consented to visit. CG1 stated Patient 8 received CHHA services once a week by CHHA1. During an interview on 12/14/2023 at 10:20 a.m. Receptionist 2 (RP2) was requested to provide CHHA1s employee record/file. During an interview on 12/14/2023 at 10:30 a.m. with Administrator/Director of Nurses Designee (AD/DD), AD/DD stated an employee record is important to have ";because its the law". During an interview on 12/14/2023 at 10:31 a.m. RP2 was requested to provide CHHA1s employee record/file. During an interview on 12/14/2023 at 10:35 a.m. RP2 stated CHHA1 did not have an employee record/file. During an interview on 12/14/2023 at 10:47 a.m. with AD/DD, AD/DD stated the Administrator/Director of Nurses (ADM/DON), and the owner were responsible for the day-to-day operations. During an interview on 12/14/2023 at 11:02 a.m. with AD/DD, AD/DD stated she does not know where employee files were. During an interview on 12/15/2023 at 12:15 p.m. with AD/DD, AD/DD stated HAs human resource director was the ADM/DON. A review of facility' undated form titled ";Job Title/Position: Secretary/Receptionist", indicated he/she must maintain the files, supplies, and general office condition in an orderly manner. Is responsible for maintaining administrative and clerical files." A review of facility' undated form titled ";Job Title/Position: Certified Hospice Aide", indicated ";Meets the training requirements of the State of California." A review of the Administrator/Director of Nurses Designee (AD/DD) HA employment application dated 12/1/2023, indicated AD/DD signed and dated form on 12/1/2023. A review of facility' undated form titled ";Job Title/Position: Executive Director/Administrator (Alternate)", indicated ";Assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. A qualified administrator appointed by and reporting to the governing body is responsible for the day-to-day operations of the hospice." The form also indicated it was signed by AD/DD on 12/1/2023. A review of facility's undated form titled ";Job Title/Position: Clinical Director/Director of Patient Care Services (Alternate)", indicated ";The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements, and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy." The form also indicated it was signed by AD/DD on 12/1/2023. A review of facility policy and procedure titled ";Personnel Record Contents" revised 4/2019, indicated ";(HA) will maintain current personnel files on all personnel. Personnel records will be retained in a manner that allows each to be easily retrievable and in keeping with timeframes of applicable local, state, and federal law.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Certified Home Health Aide 1 (CHHA1) was competent to be able to take care for one of fourteen sampled patients (Patient 8) by not providing CHHA1 employee record or documentation to verify his competency, education, and/or training. This failure had the potential to result in Patient 8 being taken care of by unqualified personnel, which had the potential to result in injury, harm, or death. --- A review of Patient 8s medical record form titled ";Patient Information", indicated Patient 8 had a start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s medical record form titled ";POC Summary" dated 12/12/2023, indicated ";CHHA services once a week for ADLs and Hygiene." A review of Patient 8s medical record form titled ";HA Assignment" dated 1/16/2023, indicated it was signed by Registered Nurse 1 (RN1). A review of Patient 8s medical record form titled ";HA Visit Note" dated 11/30/2023 and 12/5/2023, indicated both forms were signed by CHHA1. During a joint home visit on 12/13/2023 at 10:00 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, greeted at door by CG1. CG1 consented to visit. CG1 stated Patient 8 received CHHA services once a week by CHHA1. During an interview on 12/14/2023 at 10:20 a.m. Receptionist 2 (RP2) was requested to provide CHHA1s employee record/file. During an interview on 12/14/2023 at 10:30 a.m. with Administrator/Director of Nurses Designee (AD/DD), AD/DD stated an employee record is important to have ";because its the law". During an interview on 12/14/2023 at 10:31 a.m. RP2 was requested to provide CHHA1s employee record/file. During an interview on 12/14/2023 at 10:35 a.m. RP2 stated CHHA1 did not have an employee record/file. During an interview on 12/14/2023 at 10:47 a.m. with AD/DD, AD/DD stated the Administrator/Director of Nurses (ADM/DON), and the owner were responsible for the day-to-day operations. During an interview on 12/14/2023 at 11:02 a.m. with AD/DD, AD/DD stated she does not know where employee files were. During an interview on 12/15/2023 at 12:15 p.m. with AD/DD, AD/DD stated HAs human resource director was the ADM/DON. A review of facility policy and procedure titled ";Personnel Record Contents" revised 4/2019, indicated ";(HA) will maintain current personnel files on all personnel. Personnel records will be retained in a manner that allows each to be easily retrievable and in keeping with timeframes of applicable local, state, and federal law. A review of facility policy and procedure titled ";Competency Assessment" revised 4/2019, indicated ";The competence of all organization clinical personnel will be assessed during orientation, during the probation period, periodically throughout the course of the year, and during the annual performance evaluation.

Based on interview and record review, the Hospice Agency (HA) failed to ensure Certified Home Health Aide 1 (CHHA1) followed two of fourteen sampled patients' (Patient 8 and Patient 12) CHHA plan of care (individualized care plan) by not assessing patients' vital signs. This failure resulted in patients vital signs (heart rate, respiration rate, blood pressure, and temperature) not being monitored as ordered, which had the potential to result in missed abnormal readings that can lead to hospitalization. --- a. A review of Patient 8s medical record form titled ";Patient Information" indicated Patient 8 had a start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s medical record form titled ";POC Summary" dated 12/12/2023, indicated ";CHHA services once a week for ADLs and Hygiene." A review of Patient 8s medical record form titled ";HA Assignment" dated 1/16/2023, indicated ";Vitals – check vitals every visit". The form also indicated it was signed by Registered Nurse 1 (RN1). A review of Patient 8s medical record form titled ";HA Visit Note" dated 11/30/2023 and 12/5/2023, indicated Patient 8s vital signs (measurements of the body's most basic functions such as body temperature, pulse rate, respiration rate, and blood pressure) were not documented on either form. The form also indicated both forms were signed by CHHA1. During a joint home visit on 12/13/2023 at 10:00 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, greeted at door by caregiver (CG1). CG1 consented to visit. CG1 stated Patient 8 received CHHA services once a week by CHHA1. During a concurrent interview and record review on 12/14/2023 at 12:15 p.m. with Administrator/Director of Nurses Designee (AD/DD) of Patient 8s Electronic Medical Record (EMR), AD/DD stated Patient 8s CHHA care plan does not state for CHHA1 to take Patient 8s vital signs. AD/DD stated CHHA1 did not take or mentioned Patient 8s vital signs. During a concurrent interview and record review on 12/15/2023 at 11:20 a.m. with Administrator/Director of Nurses Designee (AD/DD) of Patient 8s Electronic Medical Record (EMR), AD/DD stated CHHA1 has not documented Patient 8s vital signs. AD/DD stated CHHA1 needs to monitor Patient 8s vital signs to monitor his status. b. A review of Patient 12s medical record form titled ";Patient Information" indicated Patient 12 had a start of care date of 1/13/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 12s medical record form titled ";POC Summary" dated 12/12/2023, indicated ";CHHA twice (2x/week) a week for hygiene and ADLs (Activities of Daily Living)." A review of Patient 12s medical record form titled ";HA Assignment" dated 8/14/2023, indicated ";Vitals – check vitals every visit". The form also indicated it was signed by Registered Nurse 1 (RN1). A review of Patient 12s medical record form titled ";HA Visit Note" dated 11/28/2023 and 11/24/2023, indicated Patient 12s vital signs were not documented on either form. A record review of the HAs policy and procedure titled, ";Initial Assessment", dated 2019, indicated ";Procedure...7. Based on the initial assessments, the plan of care will be initiated on the day of admission." A record review of the HAs policy and procedure titled, ";The Plan of Care", dated 2019, indicated ";Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. Procedure...1. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care...The plan of care will be reviewed prior to care being delivered."

Based on interview and record review, the Hospice Agency (HA) failed to ensure a Registered Nurse (RN) conducted Certified Home Health Aide supervisory visits every 14 days for one of fourteen sampled patients (Patient 8). This failure resulted in CHHA1 not assessing Patient 8s vital signs as ordered. It also had the potential to result in not knowing if Patient 8 and/or his care giver are content with CHHA services. --- A review of Patient 8s medical record form titled ";Patient Information" indicated Patient 8 had a start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s medical record form titled ";POC Summary" dated 12/12/2023, indicated ";CHHA services once a week for ADLs (Activities of Daily Living) and Hygiene." A review of Patient 8s medical record form titled ";HA Assignment" dated 1/16/2023, indicated ";Vitals – check vitals every visit". The form also indicated it was signed by Registered Nurse 1 (RN1). A review of Patient 8s medical record form titled ";HA Visit Note" dated 11/30/2023 and 12/5/2023, indicated Patient 8s vital signs were not documented on either form. The form also indicated both forms were signed by CHHA1. During a joint home visit on 12/13/2023 at 10:00 a.m. with Licensed Vocational Nurse 1 (LVN1) to Patient 8s home, greeted at door by caregiver (CG1). CG1 consented to visit. CG1 stated Patient 8 received CHHA services once a week by CHHA1. During a concurrent interview and record review on 12/14/2023 at 1:30 p.m. with Administrator/Director of Nurses Designee (AD/DD) of Patient 8s Electronic Medical Record (EMR), AD/DD stated she was unable to locate documentation for CHHA1s supervisory visit. AD/DD stated Patient 8s CHHA frequency was once a week. AD/DD stated CHHA supervisory visits were meant to make sure the CHHAs were doing their job properly and patients were happy with their services. AD/DD stated CHHA supervisory visits were to be done every 14 days by a Registered Nurse (RN). A review of facility's undated form titled ";Job Title/Position: Certified Hospice Aide", indicated ";The hospice aide... who works under the supervision of a registered nurse." A review of facility policy and procedure titled ";Hospice Aide supervisory Visits" revised 4/2019, indicated ";The hospice RN Case Manager will conduct supervisory visits to the patients residence at regular intervals. They must be conducted no less frequently than every 14 days."

Based on interview and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for organization and administration of services as follows: --- 1. The HA failed to ensure the acting Administrator/Director of Nurses (ADM/DON) or the acting Administrator/Director of Nurses Designee (AD/DD) managed the day-to-day operations for fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L651). 2. The HA failed to conduct or attempt to conduct counseling services - bereavement assessment to provide bereavement counseling in accordance with the patient/family's needs for eight of fourteen sampled patients (Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L652). 3. The HA failed to ensure Registered Nurse 1 was evaluated to assess his competency before providing patient care to four of fourteen sampled patients (Patient 8, Patient 9, Patient 10, and Patient 12). (Refer to L663). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with Federal regulations for organization and administration of services.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the acting Administrator/Director of Nurses (ADM/DON) or the acting Administrator/Director of Nurses Designee (AD/DD) managed the day-to-day operations for fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure resulted in lack of oversight of the care being provided adhered to hospice standards. --- 1.A review of Patient 1s ";Personal Information" sheet, indicated a start of care date of 5/9/2022, with a primary diagnosis of unspecified heart failure (heart is unable to effectively pump blood to the body). 2. A review of Patient 2s ";Personal Information" sheet, indicated a start of care date of 4/7/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). 3. A review of Patient 3s ";Personal Information" sheet, indicated a start of care date of 12/19/2022, with a primary diagnosis of unspecified heart failure (heart is unable to effectively pump blood to the body). 4. A review of Patient 4s ";Personal Information" sheet, indicated a start of care date of 10/19/2023, with a primary diagnosis of heart disease. 5. A review of Patient 5s ";Personal Information" sheet, indicated a start of care date of 12/18/2020, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). 6. A review of Patient 6s ";Personal Information" sheet, indicated a start of care date of 6/3/2021, with a primary diagnosis of heart disease. 7. A review of Patient 7s ";Personal Information" sheet, indicated a start of care date of 9/14/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). The record further indicated an end of care date of 9/16/2023, due to death. 8. A review of Patient 8s ";Patient Information" sheet, indicated a start of care date of 7/15/2022, with a primary diagnoses of Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). 9. A review of Patient 9s ";Patient Information" sheet, indicated a start of care date of 6/11/2023, with a primary diagnoses of atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). 10. A review of Patient 10s ";Patient Information" sheet, indicated a start of care date of 11/3/2021, with a primary diagnoses of Alzheimers Disease (progressive memory loss). 11. A review of Patient 11s ";Patient Information" sheet, indicated a start of care date of 10/20/2023, with a primary diagnoses of cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). 12. A review of Patient 12s ";Patient Information" sheet, indicated a start of care date of 1/13/2021, with primary diagnoses of Alzheimers Disease (progressive memory loss). 13. A review of Patient 13s ";Patient Information" sheet, indicated a start of care date of 4/1/2021, with primary diagnoses of malignant neoplasm (cancer) of prostate. 14. A review of Patient 14s ";Patient Information" sheet, indicated a start of care date of 7/20/2023, with primary diagnoses of Alzheimers Disease (progressive memory loss). During an interview on 12/12/2023 at 10:38 a.m. with volunteer coordinator (VC), VC was requested to call ADM/DON. VC stated ADM/DON did not answer her call. During an interview on 12/12/2023 at 10:58 a.m. with VC, VC stated ADM/DON was not available and will call AD/DD. During a telephone interview on 12/12/2023 at 11:02 a.m. with AD/DD, AD/DD stated would be at HA to assist in survey. AD/DD stated she did not have ADM/DONs phone number. A call was placed on 12/12/2023 at 11:10 a.m. to ADM/DON, with no answer. Message left with call back number. During an interview on 12/12/2023 at 11:49 a.m. with AD/DD, AD/DD was unable to provide HA information to be able to complete an entrance conference. AD/DD stated she was hired on 12/1/2023 and was oriented by ADM/DON that same date. AD/DD stated VC has been orienting her since. During an interview on 12/12/2023 at 12:11 p.m. with AD/DD, AD/DD was requested to provide her employee file. AD/DD stated she did not know where it was. During an interview on 12/12/2023 at 12:20 p.m. with AD/DD, AD/DD was requested to call ADM/DON. AD/DD left voice mail. During an observation on 12/12/2023 at 4:00 p.m. of VC, VC noted providing all documents requested. During an interview on 12/14/2023 at 9:50 a.m. with Receptionist 2 (RP2), RP2 was requested to inform ADM/DON her assistance is required. RP2 stated ADM/DON did not answer. During an interview on 12/14/2023 at 10:47 a.m. with AD/DD, AD/DD stated ADM/DON and the HAs owner were responsible for the day-to-day functions. AD/DD stated ADM/DON ";should call you". AD/DD stated she spoke with ADM/DON. AD/DD was requested to call ADM/DON. AD/DD placed the phone call on speaker, there was no answer. AD/DD heard leaving a message to return call. AD/DD was requested to call the HAs owner. AD/DD stated she did not have the HAs owners phone number. During an interview on 12/14/2023 at 11:02 a.m. with AD/DD, AD/DD stated she was hired on 12/1/2023. During an interview on 12/14/2023 at 12:15 p.m. with AD/DD, AD/DD stated she does not document in the HAs patients Electronic Medical Record (EMR) because she began her employment on 12/1/2023. During an interview on 12/14/2023 at 1:30 p.m. with AD/DD, AD/DD was requested to call ADM/DON. AD/DD stated there was no answer and message was left. During an interview on 12/14/2023 at 2:00 p.m. with AD/DD, AD/DD was requested to call ADM/DON. AD/DD stated there was no answer and message was left. During an interview on 12/15/2023 at 11:00 a.m. with AD/DD, AD/DD was requested to provide the HAs QAPI (quality assurance and performance improvement – a data driven and proactive approach to quality improvement). AD/DD stated she was new and did not know where the HAs QAPI was. During an interview on 12/15/2023 at 11:06 a.m. with AD/DD, AD/DD was requested to call the HAs owner and ADM/DON. AD/DD stated neither the HA owner nor the ADM/DON answered. A review of facility's undated form titled ";Employee List", indicated the Administrator/Director of Nurses (ADM/DON), was not listed on the HA employee list. A review of facility's undated form titled ";Job Title/Position: Executive Director/Administrator", indicated ";Assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. A qualified administrator appointed by and reporting to the governing body is responsible for the day-to-day operations of the hospice. The Administrator must be a hospice employee..." A review of facility's undated form titled ";Job Title/Position: Clinical Director/Director of Patient Care Services", indicated ";The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements, and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy." A review of facility's undated form titled ";Employee List", indicated the Administrator/Director of Nurses Designee (AD/DD) was listed ";Access Level – Admin Asst" and ";Discipline – RN". A review of the AD/DD, HA employment application dated 12/1/2023, indicated AD/DD signed and dated form on 12/1/2023. The application also indicated ";Position applied for – DPCS designee/ADM designee." A review of facility's undated form titled ";Job Title/Position: Executive Director/Administrator (Alternate)", indicated ";Assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. A qualified administrator appointed by and reporting to the governing body is responsible for the day-to-day operations of the hospice." The form also indicated it was signed by AD/DD on 12/1/2023. A review of facility's undated form titled ";Job Title/Position: Clinical Director/Director of Patient Care Services (Alternate)", indicated ";The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements, and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy." The form also indicated it was signed by AD/DD on 12/1/2023. A review of facility's undated form titled ";Employee List", indicated the Volunteer Coordinator (VC) was listed ";Access Level – Admin" and ";Discipline – ADMN". A review of VC, HA employment application dated 1/16/2023, indicated VC signed and dated form on 1/16/2023. The form also indicated ";Positions applied for – Volunteer Coordinator". A review of facility policy and procedure titled ";Responsibilities/Supervision of Clinical Services", revised 4/2019, indicated ";Supervision of clinical care and services will be available 24 hours a day, seven (7) days a week. The Clinical Director/Director of Patient Care Services will be responsible for the clinical direction of the organization and take reasonable steps to assure that: Care and services provided by organization personnel and contracted organization personnel are coordinated and integrated. The Clinical Director/Director of Patient Care Services will oversee the day-to-day clinical operations." A review of facility policy and procedure titled ";Administrative Qualifications and Responsibilities", revised 4/2019, indicated ";(HA) position descriptions will clearly define specific responsibilities and include at least: Organization and direction of the operations to assure availability and provision of care and services; compliance with applicable law and regulation." A review of facility policy and procedure titled ";Hospice Administrator", revised 4/2019, indicated ";The Executive Director/Administrator position will be responsible for the direction, coordination, and general supervision of all hospice services." A review of facility policy and procedure titled ";Designation of Individual in Absence of Executive Director/Administrator", revised 4/2019, indicated ";(HA) will have an Executive Director/Administrator or designee available at all times. In the event that the Executive Director/Administrator is absent, the Clinical Director/Director of Patient Care Services will assume the operational duties and responsibilities at (HA). In the event both are absent, an appropriate qualified nurse will assume the responsibilities. These individuals have been identified to act on behalf of the Executive Director/Administrator in his/her absence."

Based on interview and record review, the Hospice Agency (HA) failed to conduct or attempt to conduct counseling services - bereavement assessment to provide bereavement counseling in accordance with the patient/family's needs for eight of fourteen sampled patients (Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This deficient practice had the potential for the patient/family not being provided social, spiritual, and cultural support related to the patient's death. --- a. A review of Patient 7s ";Personal Information" sheet, indicated a start of care date of 9/14/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). The record further indicated an end of care date of 9/16/2023, due to death. During a concurrent interview and record review on 12/15/2023, at 11:28 a.m., the Administrator/Director of Nurses Designee (AD/DD) reviewed Patient 7s clinical records. The AD/DD stated there was no bereavement plan of care and did not know why. When asked about the importance of a bereavement plan of care, the AD/DD stated, ";So we know we provided the service. We have to document everything. Nurse has to notify the doctor, notify mortuary (funeral home or morgue), dispose of medication, prepare the body, and provide support to the family. All this should be in the bereavement POC (plan of care)." During a concurrent interview and record review on 12/15/2023, at 11:32 a.m., the AD/DD reviewed Patient 7s clinical records. The AD/DD stated there was no post death bereavement assessment and did not know why it had not done. The AD/DD stated the purpose of the assessment was to make sure all the services were provided: notification of doctor, notifying mortuary, assessing family support, and making sure MSW (Medical Social Worker) and SC (Spiritual Counselor) are available to the patient, so we continue to provide services to the family. During a concurrent interview and record review on 12/15/2023, at 11:34 a.m., the AD/DD reviewed Patient 7s clinical records. The AD/DD stated there was no indication letters were sent to the caregiver/family and did not know why. The AD/DD stated the office staff was supposed to provide them at one month, three months, six months, and yearly. The AD/DD stated the purpose of the letters was part of the plan of care, to follow up and let them know someone cares about them. b. A review of Patient 8s medical record form titled ";Patient Information" indicated Patient 8 had a start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s medical record form titled ";Comprehensive Nursing Assessment" dated 7/15/2022, indicated SW (Social Worker), SC (Spiritual Counselor), and BC (Bereavement Counselor) visits were needed. A review of Patient 8s medical record form titled ";POC/IDG Review" dated 11/29/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: patients primary bereaved will experience non-complicated grieving process, and bereaved will verbalized accepting of terminal diagnosis by next recertification. Intervention: will continue to follow up for any changes in grieving process. Assist family with grieving process. Assist primary bereaved in coping with the dying process and death and re-assess post death bereavement. Offer encouraging tips and resources to get through grief. Attentive listening, understand their loss. Offer encouraging tips to get through grief." A review of Patient 8s undated medical record form titled ";History of Bereavement Assessment", indicated there were no assessments documented; form was blank. During a concurrent interview and record review on 12/12/2023 at 4:00 p.m. with the Volunteer Coordinator (VC) of Patient 8s Electronic Medical Record (EMR), VC coordinator stated Patient 8 did not have any bereavement assessments documented. During an interview on 12/14/2023 at 12:45 p.m. with Administrator/Director of Nurses Designee (AD/DD), AD/DD stated initial bereavement assessments should be completed by either the chaplain or the social worker within five days of admission. AD/DD stated if not completed, staff would not know who needs the bereaved services and can cause the family to get frustrated and unhappy. The HA failed to ensure an initial bereavement assessment was conducted for Patient 8 and/or caregiver (CG1) within five days of the admission date. c. A review of Patient 9s medical record form titled ";Patient Information" indicated Patient 9 had start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). A review of Patient 9s medical record form titled ";Comprehensive Nursing Assessment" dated 6/11/2023, indicated SW (Social Worker), SC (Spiritual Counselor), and BC (Bereavement Counselor) visits were needed. A review of Patient 9s medical record form titled ";POC/IDG Review" dated 11/29/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: patients primary bereaved will experience non-complicated grieving process, and bereaved will verbalized accepting of terminal diagnosis by next recertification. Intervention: will continue to follow up for any changes in grieving process. Assist family with grieving process. Assist primary bereaved in coping with the dying process and death and re-assess post death bereavement. Offer encouraging tips and resources to get through grief. Attentive listening, understand their loss. Offer encouraging tips to get through grief. A review of Patient 9s medical record form titled ";Bereavement Assessment" dated 7/7/2023, indicated form was not completed. The form also indicated there was no documentation in the ";Narrative Section" and it was not signed by HA staff. During a concurrent interview and record review on 12/12/2023 at 4:00 p.m. with the Volunteer Coordinator (VC) of Patient 9s Electronic Medical Record (EMR), VC coordinator stated Patient 9 did have a bereavement assessment dated 7/7/2023, but it was not completed, and it was not signed by HA staff. VC stated she did not know who started the documentation on the form and that it should have been completed within five days of admission. The HA failed to ensure an initial bereavement assessment was conducted for Patient 9 and/or CG2 within five days of the admission date. d. A review of Patient 10s medical record form titled ";Patient Information" indicated Patient 10 had a start of care date of 11/3/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 10s medical record form titled ";Comprehensive Nursing Assessment" dated 11/3/2021, indicated SW (Social Worker), SC (Spiritual Counselor), and BC (Bereavement Counselor) visits were needed. A review of Patient 10s medical record form titled ";POC/IDG Review" dated 11/29/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: patients primary bereaved will experience non-complicated grieving process, and bereaved will verbalized accepting of terminal diagnosis by next recertification. Intervention: will continue to follow up for any changes in grieving process. Assist family with grieving process. Assist primary bereaved in coping with the dying process and death and re-assess post death bereavement. Offer encouraging tips and resources to get through grief. Attentive listening, understand their loss. Offer encouraging tips to get through grief. A review of Patient 10s undated medical record form titled ";History of Bereavement Assessment", indicated there were no assessments documented; form was blank. During a concurrent interview and record review on 12/12/2023 at 4:00 p.m. with the Volunteer Coordinator (VC) of Patient 10s Electronic Medical Record (EMR), VC coordinator stated Patient 10 did not have any bereavement assessments documented. The HA failed to ensure an initial bereavement assessment was conducted for Patient 10 within five days of the admission date. e. A review of Patient 11s medical record form titled ";Patient Information" indicated Patient 11 had a start of care date of 10/20/2023, with diagnoses including cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). A review of Patient 11s medical record form titled ";Comprehensive Nursing Assessment" dated 10/20/2023, indicated SW (Social Worker), SC (Spiritual Counselor), and BC (Bereavement Counselor) visits were needed. A review of Patient 11s medical record form titled ";POC/IDG Review" dated 11/29/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: patients primary bereaved will experience non-complicated grieving process, and bereaved will verbalized accepting of terminal diagnosis by next recertification. Intervention: will continue to follow up for any changes in grieving process. Assist family with grieving process. Assist primary bereaved in coping with the dying process and death and re-assess post death bereavement. Offer encouraging tips and resources to get through grief. Attentive listening, understand their loss. Offer encouraging tips to get through grief. A review of Patient 11s undated medical record form titled ";History of Bereavement Assessment", indicated there were no assessments documented; form was blank. During a concurrent interview and record review on 12/12/2023 at 4:00 p.m. with the Volunteer Coordinator (VC) of Patient 11s Electronic Medical Record (EMR), VC coordinator stated Patient 11 did not have any bereavement assessments documented. The HA failed to ensure an initial bereavement assessment was conducted for Patient 11 within five days of the admission date. f. A review of Patient 12s medical record form titled ";Patient Information" indicated Patient 12 had a start of care date of 1/13/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 12s medical record form titled ";Comprehensive Nursing Assessment" dated 1/13/2021, indicated SW (Social Worker), SC (Spiritual Counselor), and BC (Bereavement Counselor) visits were needed. A review of Patient 12s medical record form titled ";POC/IDG Review" dated 1/13/2021, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: complete initial bereavement assessment in five days. Intervention: Assist family with grieving process. Assist primary bereaved in coping with the dying. Attentive listening, understand their loss. Offer encouraging tips to get through grief. A review of Patient 12s undated medical record form titled ";History of Bereavement Assessment", indicated there were no assessments documented; form was blank. During a concurrent interview and record review on 12/12/2023 at 4:00 p.m. with the Volunteer Coordinator (VC) of Patient 12s Electronic Medical Record (EMR), VC coordinator stated Patient 12 did not have any bereavement assessments documented. The HA failed to ensure an initial bereavement assessment was conducted for Patient 12 within five days of the admission date. g. A review of Patient 13s medical record form titled ";Patient Information" indicated Patient 13 had a start of care date of 4/1/2021, with diagnoses including malignant neoplasm (cancer) of prostate. A review of Patient 13s medical record form titled ";Comprehensive Nursing Assessment" dated 4/1/2023, indicated SW (Social Worker), SC (Spiritual Counselor), and BC (Bereavement Counselor) visits were needed. A review of Patient 13s medical record form titled ";POC/IDG Review" dated 6/22/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: patients primary bereaved will experience non-complicated grieving process, and bereaved will verbalized accepting of terminal diagnosis by next recertification. Intervention: will continue to follow up for any changes in grieving process. Assist family with grieving process. Assist primary bereaved in coping with the dying process and death and re-assess post death bereavement. Offer encouraging tips and resources to get through grief. Attentive listening, understand their loss. Offer encouraging tips to get through grief. A review of Patient 13s undated medical record form titled ";History of Bereavement Assessment", indicated there were no assessments documented; form was blank. During a concurrent interview and record review on 12/12/2023 at 4:00 p.m. with the Volunteer Coordinator (VC) of Patient 13s Electronic Medical Record (EMR), VC coordinator stated Patient 13 did not have any bereavement assessments documented. The HA failed to ensure an initial bereavement assessment was conducted for Patient 13 within five days of the admission date. h. A review of Patient 14s medical record form titled ";Patient Information" indicated Patient 14 had a start of care date of 7/20/2023, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 14s medical record form titled ";POC/IDG Review" dated 9/9/2023, indicated ";Plan of Care (Problem/Intervention/Goals/Status) – Bereavement – Goal: patients primary bereaved will experience non-complicated grieving process, and bereaved will verbalized accepting of terminal diagnosis by next recertification. Intervention: will continue to follow up for any changes in grieving process. Assist family with grieving process. Assist primary bereaved in coping with the dying process and death and re-assess post death bereavement. Offer encouraging tips and resources to get through grief. Attentive listening, understand their loss. Offer encouraging tips to get through grief. A review of Patient 14s undated medical record form titled ";History of Bereavement Assessment", indicated there were no assessments documented; form was blank. During a concurrent interview and record review on 12/12/2023 at 4:00 p.m. with the Volunteer Coordinator (VC) of Patient 14s Electronic Medical Record (EMR), VC coordinator stated Patient 14 did not have any bereavement assessments documented. During a concurrent interview and record review on 12/15/2023 at 12:40 p.m. with the Administrator/Director of Nurses Designee (AD/DD) of Patient 14s medical record, AD/DD stated Patient 14's end of care date was on 9/9/2023 due to death. AD/DD stated Patient 14 did not have a bereavement assessment, including a post bereavement assessment. AD/DD stated the social worker had a responsibility to call Patient 14s family after her death. AD/DD stated social services had to be involved to provide support to the family and to assess if additional support was needed. The HA failed to ensure an initial bereavement assessment was conducted for Patient 14 within five days of the admission date. During an interview on 12/14/2023 at 12:45 p.m. with Administrator/Director of Nurses Designee (AD/DD), AD/DD stated initial bereavement assessments should be completed by either the chaplain or the social worker within five days of admission. AD/DD stated if not completed, staff would not know who needs the bereaved services and can cause the family to get frustrated and unhappy. During a telephone interview on at 12/15/2023 at 10:43 a.m. with Medical Social Worker 2 (MSW2), MSW2 stated she assist patient and their families with resources, emotional support, paperwork, Medicare, and her main job is to provide support and listen to them vent out their feelings and concerns. MSW2 stated she has five days to complete and document an initial bereavement assessment. MSW2 stated she is responsible for assessing their initial bereavement assessment within five days of admission. A review of facilitys public brochure, undated, indicated ";The Hospice Bereavement Coordinator works with the family and develops a plan to support and help them during their time of loss. The Bereavement Coordinator is a specialist who is aware of the difficulties and needs of a family as they go through this time of loss. Social work and chaplain visits to assist with final arrangements and bereavement care afterwards." A review of facility policy and procedure titled ";Psychosocial Services" revised 4/2019, indicated ";(HA) will provide psychosocial services by qualified social workers (MSW, BSW) under the direction of a physician and in accordance with the plan of care. Psychosocial services will include: assessing emotional factors related to terminal illness; patient and family/caregiver counseling around issues of death, dying, and grief...Assessment activities of the social worker will include but not be limited to: Bereavement needs." A review of facility policy and procedure titled ";Bereavement Services" revised 4/2019, indicated ";(HA) will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one (1) year following the death of the patient. The program will provide bereavement services to the families/caregivers of hospice patients both before and after the patients death in accordance with the plan of care. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. A plan will be developed to address bereavement/grief issues and will be implemented as needed. After death has occurred, the bereavement assessment will be updated, and the family/caregiver will be discussed at the next interdisciplinary group meeting."

Based on interview and record review, the Hospice Agency (HA) failed to ensure Registered Nurse 1 was evaluated to assess his competency before providing patient care to four of fourteen sampled patients (Patient 8, Patient 9, Patient 10, and Patient 12). This failure resulted in patients receiving care from a nurse whose skills and knowledge were not verified. --- a. A review of Patient 8s medical record form titled ";Patient Information" indicated Patient 8 had a start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s medical record form titled ";Comprehensive Nursing Assessment" dated 7/15/2023 and ";Re-Cert Assessment" dated 12/11/2023, indicated both forms were signed by RN1. b. A review of Patient 9s medical record form titled ";Patient Information" indicated Patient 9 had a start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). A review of Patient 9s medical record form titled ";Re-Cert Assessment" dated 10/22/2023, indicated RN1 signed the form. c. A review of Patient 10s medical record form titled ";Patient Information" indicated Patient 10 had a start of care date of 11/3/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 10s medical record form titled ";Re-Cert Assessment" dated 12/5/2023, indicated RN1 signed the form. d. A review of Patient 12s medical record form titled ";Patient Information" indicated Patient 12 had a start of care date of 1/13/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 12s medical record form titled ";Re-Cert Assessment" dated 12/11/2023, indicated RN1 signed the form. A review of the Administrator/Director of Nurses Designee (AD/DD) HA employment application dated 12/1/2023, indicated AD/DD signed and dated form on 12/1/2023. A review of Registered Nurse 1 (RN1) forms titled ";Performance Evaluation" dated 12/14/2021, 9/26/2022, and 9/30/2021, were reviewed and signed by AD/DD. During a concurrent interview and record review on 12/14/2023 at 11:02 a.m. with AD/DD of RN1s employee file, AD/DD identified her signatures on RN1s Performance Evaluation dated 12/14/2021 and 9/26/2022. AD/DD stated she was hired on 12/1/2023. AD/DD stated she did not pay attention to what she was signing and stated those were not her signatures after inquiring on her signature dates. During an interview on 12/14/2023 12:15 p.m. with AD/DD, AD/DD stated, ";No, I have not been able to get a hold of the nurse (RN1) who assessed the patients, he might be on vacation." A review of Patient 11s medical record titled ";Audit Log" dated 12/12/2023 to 12/15/2023, indicated Registered Nurse 1 (RN1) documented under ";IDG – Update Item" on 12/14/2023. A review of Patient 12s medical record titled ";Audit Log" dated 12/12/2023 to 12/15/2023, indicated Registered Nurse 1 (RN1) documented under ";IDG – Summary Discussion" on 12/14/2023. A review of Patient 14s medical record titled ";Audit Log" dated 12/12/2023 to 12/15/2023, indicated Registered Nurse 1 (RN1) documented under ";visit note – Narrative" on 12/14/2023. A review of facility policy and procedure titled ";Personnel Record Contents" revised 4/2019, indicated ";(HA) will maintain current personnel files on all personnel. Personnel records will be retained in a manner that allows each to be easily retrievable and in keeping with timeframes of applicable local, state, and federal law. A review of facility policy and procedure titled ";Competency Assessment" revised 4/2019, indicated ";The competence of all organization clinical personnel will be assessed during orientation, during the probation period, periodically throughout the course of the year, and during the annual performance evaluation.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Medical Director was met as evidenced by: --- 1. The HA failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) reviewed patients clinical information to determine hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care criteria is met and/or provide an initial written certification that the patient had six months or less to live if the illness runs its normal course for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 12, and Patient 14). (Refer to L 667). 2. The HA failed to ensure the medical director and/or physician designee conducted a review and verified the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, Patient 10, and Patient 12). (Refer to L 668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) reviewed patients clinical information to determine hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care criteria is met and/or provide an initial written certification that the patient had six months or less to live if the illness runs its normal course for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 12, and Patient 14). These deficient practices resulted in the hospice medical director and/or the designee certified patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses. It also resulted in patients not being certified by a medical doctor for hospice care, which can result lack and inappropriate care provided to the patients. --- 1.A review of Patient 1s ";Personal Information" sheet, indicated a start of care date on 5/9/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). During an observation of a home visit on 12/13/2023, at 10:40 a.m., Registered Nurse 2 (RN 2) provided care to Patient 1. During an interview at the home visit on 12/13/2023, at 10:57 a.m., Patient 1s caregiver (CG 3) stated she takes Patient 1 to the mall to walk. CG 3 stated Patient 1 used a walker to walk slowly at the mall. CG 3 stated Patient 1 did not have shortness of breath when walking at the mall or when walking two blocks around her home. During an interview at the home visit on 12/13/2023, at 11:15 a.m., Patient 1 stated the HA provided oxygen to her, but she did not use it. Patient 1 state the last time she used oxygen was 6 months ago when she was sick. Patient 1 stated she did not need oxygen when walking. During an interview at the home visit on 12/13/2023, at 11:44 a.m., Patient 1 stated no doctor had told her she was dying. Patient 1 stated no doctor had told her she had 6 months or less to live. During an interview at the home visit on 12/13/2023, at 12:00 p.m., Patient 1s daughter (CG 4) stated she did not know her mother was in hospice care. CG 4 stated her mother was not dying and thought the nurse who was visiting her was from the insurance plan, not a hospice agency. During a concurrent interview and record review on 12/15/2023, at 11:38 a.m., the Administrator/Director of Nurses designee (AD/DD) reviewed Patient 1s record titled, ";Comprehensive Nursing Assessment", dated 5/9/2022. The record indicated the LCD (Local Criteria Determination, a tool used to qualify a patient for hospice care services) indicated Patient 1 was eligible for hospice care services because Patient 1 had been ruled out as a candidate for surgical procedures and her Congestive Heart Failure (CHF) met the criteria for NYHA (New York Heart Association-classifies the extend of heart failure) class IV (4) level (Class IV-severe limitation. Experiences symptoms even while at rest. Mostly bedbound patients.) The AD/DD stated the information used to complete the LCD was gathered from the referring doctor. The AD/DD stated there were no medical records to support the diagnosis and findings of heart failure. The AD/DD stated the assessment was not accurate because the HA did not have supportive documents to support Patient 1s diagnosis. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. By being in hospice, Patient 1 might not be eligible for other services. Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 1 might need. During an interview on 12/14/2023, at 11:40 a.m., Medical Director 3 (MD 3) stated she used the nursing assessment and evaluation from the referring doctor to determine certification into the hospice program. MD 3 stated ideally, she would like to review any medical records of all patients, as this is the way to comply. During a concurrent interview and record review on 12/14/20223, at 12:02 p.m., MD 3 reviewed Patient 1s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 5/9/2022 to 8/6/2022. The record indicated, ";Certifying Physician Summary...Patient is short of breath at rest and with minimal ambulation with severe chest pain. Supplemental o2 (oxygen) has been prescribed." MD 3 stated her certification was based on the nurses assessment, what the nurse mentioned. MD 3 stated she did not use any medical assessments, history and physical, cardiologist (doctor who specializes in the heart) notes. The HA failed to ensure the CTI had supportive evidence of Patient 1s heart failure to validate an admission to hospice care. 2.A review of Patient 2s ";Personal Information" sheet, indicated a start of care date on 4/7/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). During an interview on 12/14/2023 at 8:55 a.m., Patient 2s daughter (CG 5) stated it was a mistake her mother was in hospice care, as she was not supposed to be in the hospice program. CG 5 stated Patient 2 was not dying, as no doctor had told her and Patient 2 she had 6 months or less to live. CG 5 stated she informed the HA her mother did not need hospice services, since her mother was not terminal, and has never been considered terminal. During a concurrent interview and record review on 12/15/2023, at 11:48 a.m., the AD/DD reviewed Patient 2s record titled, ";Comprehensive Nursing Assessment", dated 4/7/2023. The record indicated the LCD indicated Patient 2 was eligible for hospice care services due to inability to carry out activities of daily living and inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months. The AD/DD stated there was no documents such as a history and physical (a document that explains the past and current medical history, assessment findings, and plan), doctors notes, or test results to support a diagnosis of Alzheimers disease. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. By being in hospice, Patient 2 might not be eligible for other services. Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 2 might need. During a concurrent interview and record review on 12/14/20223, at 12:06 p.m., MD 3 reviewed Patient 2s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 4/7/2023 to 6/5/2023. The record indicated, ";Certifying Physician Summary...despite aggressive treatment, the patients condition has progressed...She does not have ability to maintain sufficient fluid and caloric intake with unintentional weight loss of 10% or more of body weight in the last six months...I attest that patient has a prognosis of six months or less if the disease runs its normal course." MD 3 stated she did not look at any medical documents because the HA did not have them, and they were in the process of getting them. MD 3 stated this was another patient they were working on discharging. The HA failed to ensure the CTI had supportive evidence of Patient 2s Alzheimers disease to validate an admission to hospice care. 3. A review of Patient 3s ";Personal Information" sheet, indicated a start of care date on 12/19/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). During an interview on 12/14/2023, at 9:00 a.m., Patient 3s daughter (CG 6) stated she did not know how her mother was enrolled in hospice care because she is not dying. CG 6 stated no doctor has told her and her mother Patient 3 is dying in 6 months or less. CG 6 stated her mother was no dying, ";shes just old". During a concurrent interview and record review on 12/15/2023, at 11:54 a.m., the AD/DD reviewed Patient 3s record titled, ";Comprehensive Nursing Assessment", dated 12/29/2022. The record indicated the LCD indicated Patient 3 was eligible for hospice care services because Patient 3 had been ruled out as a candidate for surgical procedures, declined surgical procedures and CHF met the criteria for NYHA class IV (4).. The AD/DD stated she did not know where the information came from. The AD/DD stated there were no medical records to support the diagnosis and findings of heart failure. The AD/DD stated the assessment was not accurate because the HA did not have supportive documents to support Patient 3s diagnosis. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. By being in hospice, Patient 3 might not be eligible for other services. Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 3 might need. During a concurrent interview and record review on 12/14/20223, at 12:09 p.m., MD 3 reviewed Patient 3s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 12/19/2022 to 2/6/2022. The record indicated, ";Certifying Physician Summary...Based on advanced heart disease she is eligible for hospice per LCD guidelines." MD 3 stated Patient 3 came from another hospice agency. If there were medical records, they should have been in her medical file. MD 3 stated she used the nursing assessment in certifying Patient 3 to hospice care. The HA failed to ensure the CTI had supportive evidence of Patient 3s heart failure to validate an admission to hospice care. 4. A review of Patient 4s ";Personal Information" sheet, indicated a start of care date on 10/19/2023, with a primary diagnosis of heart disease. During an interview on 12/14/2023, at 9:35 a.m., Patient 4 stated she learned about the HA when she visited a rehabilitation center, ";they were outside giving a flyer, I asked them if it was legal or not. They told me it was legal because its a Medicare program". Patient 4 stated she was not dying, and no doctor had told her she had 6 months or less to live. Patient 4 stated she had a primary care doctor, with the last visit being on September 30, 2023. Patient 4 stated her primary care doctor said she was okay. Patient 4 stated she was able to walk with a cane, did not need oxygen, was able to dress and shower by herself. During a concurrent interview and record review on 12/15/2023, at 11:58 a.m., the AD/DD reviewed Patient 4s record titled, ";Comprehensive Nursing Assessment", dated 10/19/2023. The record indicated the LCD indicated Patient 4 was eligible for hospice care services because Patient 4 had declined surgical procedures, was treated for heart disease with diuretics (medications that get rid of excess water in the body) and vasodilators (medications that lower the blood pressure) and CHF met the criteria for NYHA class IV (4). The AD/DD stated she did not know where the information came from. The AD/DD stated there were no medical records to support the diagnosis and findings of heart failure. The AD/DD stated the assessment was not accurate because the HA did not have supportive documents to support Patient 4s diagnosis. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. By being in hospice, Patient 4 might not be eligible for other services. Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 4 might need. During a concurrent interview and record review on 12/14/20223, at 12:13 p.m., MD 3 reviewed Patient 4s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 10/19/2023 to 1/16/2024. The record indicated, ";Certifying Physician Summary...requires moderate to maximal assistance with her ADLs (activities of daily living). She is NYHA Class IV. She has...intermittent shortness of breath at rest and with minimal movement." MD 3 stated she had not seen Patient 4 and she certified the patient ";strictly based on the nursing evaluation." The HA failed to ensure the CTI had supportive evidence of Patient 4s heart failure to validate an admission to hospice care. A review of Patient 8s medical record form titled ";Patient Information" indicated Patient 8 start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). 5.A review of Patient 8s medical record form titled ";Physicians Certification for Hospice Benefits" dated 7/15/2023 to 10/12/2023, indicated it was electronically signed by Medical Director (MD3) on 7/15/2023. A review of Patient 8s medical record titled ";Audit Log (a chronological record of system activities)" dated 7/15/2022 to 12/14/2023, indicated Medical Director 3 (MD3) signed Patient 8s CTI dated 7/15/2022 on 8/3/2022. During a joint home visit on 12/13/2023 at 10 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, Patient 8s Care Giver (CG1) stated she or Patient 8 had never been told Patient 8 had six months or less to live. CG1 stated Patient 8 is not dying. CG1 stated Patient 8 was diagnosed with diabetes (high blood sugar) about ten years ago and has been taking medications for it since. CG1 stated she was unable to speak English and required an interpreter. LVN1 called an HA interpreter to assist with translation. During a telephone interview on 12/14/2023 at 11:38 a.m. with MD3, MD3 stated Patient 8 was referred to hospice care by MD4. MD3 stated used the admitting Registered Nursing assessment to determine Patient 8 was eligible for hospice care. MD3 stated Care Giver 1 (CG1) monitors Patient 8s blood sugars. MD3 stated Patient 8s history and physical (H&P) was not uploaded into the HAs patients Electronic Medical Record (EMR). MD3 stated Receptionist 2 (RP2) should have filed Patient 8s H&P in his paper chart. 6.A review of Patient 9s medical record form titled ";Patient Information" indicated Patient 9 start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). A review of Patient 9s medical record form titled ";Physicians Certification for Hospice Benefits" dated 6/11/2023 to 9/8/2023, indicated it was electronically signed by MD3 on 7/7/2023. A review of Patient 9s medical record titled ";Audit Log" dated 6/11/2023 to 12/14/2023, indicated Registered Nurse 1 (RN1) documented under the Physician Narrative Certifying Physician Summary for Patient 9s CTI dated 6/11/2023 on 8/7/2023. It also indicated Medical Director 3 (MD3) signed Patient 9s CTI dated 6/11/2023 on 9/4/2022. During a joint home visit on 12/13/2023 at 11:45 a.m. with License Vocational Nurse 1 (LVN1) to Patient 9s home, Patient 9 noted sitting on couch in living room, got off from couch and excused herself to the restroom, then ambulated unassisted. Patient 9 stated she ambulates around her street block every day to maintain healthy. Patient 9s Care Giver (CG2) stated he or Patient 9 had never been told Patient 9 had six months or less to live. CG2 stated Patient 9 is not dying. CG2 stated Patient 9 was seen by her primary physician a month ago for her yearly physical and they stated she was doing fine. CG2 stated they were not aware Patient 9 had a hospice doctor and stated hospice doctor was not needed because she had her own. CG2 stated he speaks limited English and required an interpreter. During a telephone interview on 12/14/2023 at 11:38 a.m. with MD3, MD3 stated Patient 9 was dependent on all activities and becomes short of breath when ";moving around". MD3 stated Patient 9 was mostly in bed in November 2023. MD3 stated if she was made aware that Patient 9 was able to ambulate, she would not have certified her for hospice care. MD3 stated Patient 9s history and physical (H&P) was not uploaded into the HAs patients Electronic Medical Record (EMR). MD3 stated Receptionist 2 (RP2) should have filed Patient 9s H&P in his paper chart. 7.A review of Patient 10s medical record form titled ";Patient Information" indicated Patient 10 start of care date of 11/3/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefits" dated 11/3/2021 to 1/31/2022, indicated it was electronically signed by Registered Nurse 3 (RN3) on 11/3/2021. A review of Patient 10s medical record titled ";Audit Log" dated 11/3/2023 to 12/14/2023, indicated Registered Nurse 3 (RN3) documented under the Physician Narrative Certifying Physician Summary for Patient 10s CTI dated 11/3/2021 on 11/11/2021. 8.A review of Patient 12s medical record form titled ";Patient Information" indicated Patient 12 start of care date of 1/13/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefits" dated 1/13/2021 to 4/12/2021, indicated it was electronically signed by Medical Doctor 5 (MD5) on 1/13/2021. A review of Patient 12s medical record titled ";Audit Log" dated 1/15/2021 to 12/14/2023, indicated Medical Director 5 (MD5) signed Patient 12s CTI dated 1/13/2021 on 1/17/2021. 9.A review of Patient 14s medical record form titled ";Patient Information" indicated Patient 14 start of care date of 7/20/2023, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 14s medical record form titled ";Physicians Certification for Hospice Benefits" dated 7/20/2023 to 9/17/2022, indicated it was electronically signed by MD3 on 7/17/2023. A review of Patient 14s medical record titled ";Audit Log" dated 7/21/2023 to 12/14/2023, indicated Medical Director 1 (MD1) signed Patient 14s CTI dated 7/20/2023 on 8/1/2023. During a telephone interview on 12/14/2023 at 11:38 a.m. with MD3, MD3 stated she uses a combination of LCD guidelines and other signs and symptoms to admit patients for hospice care. MD3 stated she relies on the admitting Registered Nurse assessment to determine hospice eligibility. MD3 stated the way to comply was to review any medical record available and rely on face-to-face evaluations. MD3 stated she was behind on patients certification for terminal illness documentation. MD3 stated no one was allowed to document under patients certification for terminal illness form. MD3 stated no one had her EMR log in information. MD3 stated ";My understanding is that when they sign for hospice the services are explained already, I assume when I tell them that I am their doctor they know that I am." MD3 stated ";I rely on the hospice that the multidisciplinary team are involved, and the family understand what hospice services is. That is not under my control." MD3 stated ";The initial CTI, the first certification is the RNs evaluation." During a concurrent interview and record review on 12/14/2023 at 12:15 p.m. with the Administrator/Director of Nurses Designee (AD/DD) of HAs EMR, AD/DD stated they did not have any of the sample patients history and physical in their EMR system or in their paper charts. AD/DD stated, ";The admitting nurse responsibility is to do a patient assessment, input the information and report to the doctor and submit documentation." During an interview on 12/14/2023 at 12:45 p.m. with the AD/DD, AD/DD stated CTIs are to be signed within 48 hours of completion. AD/DD stated the physician is supposed to fill out the narrative section and sign patients CTI. A review of facilitys public brochure, undated, indicated ";Hospice Medical Director works with attending physician..." A review of facility form titled ";Employee List" undated, indicated the Volunteer Coordinator (VC) was listed ";Access Level – Admin" and ";Discipline – ADMN". A review of VCs, HA employment application dated 1/16/2023, indicated VC signed and dated form on 1/16/2023. It also indicated ";Positions applied for – Volunteer Coordinator". A record review of the HAs policy and procedure titled, ";Certification of Terminal Illness" revised 4/2019, indicated ";When certifying the patient as terminally ill, the hospice medical director must considerate least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. The certification may be completed no more that fifteen (15) calendar days prior to the effective date of the hospice election. " A record review of the HAs policy and procedure titled, ";Physician Services – Medical Director" revised 4/2019, indicated ";The duties and responsibilities of the Medical Director will include, but not be limited to, the following: Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care. Documenting care provided in the patients clinical record, providing evidence of progression of the end-stage disease process." 1.A review of Patient 1s ";Personal Information" sheet, indicated a start of care date on 5/9/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). During an observation of a home visit on 12/13/2023, at 10:40 a.m., Registered Nurse 2 (RN 2) provided care to Patient 1. During an interview at the home visit on 12/13/2023, at 10:57 a.m., Patient 1s caregiver (CG 3) stated she takes Patient 1 to the mall to walk. CG 3 stated Patient 1 used a walker to walk slowly at the mall. CG 3 stated Patient 1 did not have shortness of breath when walking at the mall or when walking two blocks around her home. During an interview at the home visit on 12/13/2023, at 11:15 a.m., Patient 1 stated the HA provided oxygen to her, but she did not use it. Patient 1 state the last time she used oxygen was 6 months ago when she was sick. Patient 1 stated she did not need oxygen when walking. During an interview at the home visit on 12/13/2023, at 11:44 a.m., Patient 1 stated no doctor had told her she was dying. Patient 1 stated no doctor had told her she had 6 months or less to live. During an interview at the home visit on 12/13/2023, at 12:00 p.m., Patient 1s daughter (CG 4) stated she did not know her mother was in hospice care. CG 4 stated her mother was not dying and thought the nurse who was visiting her was from the insurance plan, not a hospice agency. During a concurrent interview and record review on 12/15/2023, at 11:38 a.m., the Administrator/Director of Nurses designee (AD/DD) reviewed Patient 1s record titled, ";Comprehensive Nursing Assessment", dated 5/9/2022. The record indicated the LCD (Local Criteria Determination, a tool used to qualify a patient for hospice care services) indicated Patient 1 was eligible for hospice care services because Patient 1 had been ruled out as a candidate for surgical procedures and her Congestive Heart Failure (CHF) met the criteria for NYHA (New York Heart Association-classifies the extend of heart failure) class IV (4) level (Class IV-severe limitation. Experiences symptoms even while at rest. Mostly bedbound patients.) The AD/DD stated the information used to complete the LCD was gathered from the referring doctor. The AD/DD stated there were no medical records to support the diagnosis and findings of heart failure. The AD/DD stated the assessment was not accurate because the HA did not have supportive documents to support Patient 1s diagnosis. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. By being in hospice, Patient 1 might not be eligible for other services. Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 1 might need. During an interview on 12/14/2023, at 11:40 a.m., Medical Director 3 (MD 3) stated she used the nursing assessment and evaluation from the referring doctor to determine certification into the hospice program. MD 3 stated ideally, she would like to review any medical records of all patients, as this is the way to comply. During a concurrent interview and record review on 12/14/20223, at 12:02 p.m., MD 3 reviewed Patient 1s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 5/9/2022 to 8/6/2022. The record indicated, ";Certifying Physician Summary...Patient is short of breath at rest and with minimal ambulation with severe chest pain. Supplemental o2 (oxygen) has been prescribed." MD 3 stated her certification was based on the nurses assessment, what the nurse mentioned. MD 3 stated she did not use any medical assessments, history and physical, cardiologist (doctor who specializes in the heart) notes. The HA failed to ensure the CTI had supportive evidence of Patient 1s heart failure to validate an admission to hospice care. 2.A review of Patient 2s ";Personal Information" sheet, indicated a start of care date on 4/7/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). During an interview on 12/14/2023 at 8:55 a.m., Patient 2s daughter (CG 5) stated it was a mistake her mother was in hospice care, as she was not supposed to be in the hospice program. CG 5 stated Patient 2 was not dying, as no doctor had told her and Patient 2 she had 6 months or less to live. CG 5 stated she informed the HA her mother did not need hospice services, since her mother was not terminal, and has never been considered terminal. During a concurrent interview and record review on 12/15/2023, at 11:48 a.m., the AD/DD reviewed Patient 2s record titled, ";Comprehensive Nursing Assessment", dated 4/7/2023. The record indicated the LCD indicated Patient 2 was eligible for hospice care services due to inability to carry out activities of daily living and inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months. The AD/DD stated there was no documents such as a history and physical (a document that explains the past and current medical history, assessment findings, and plan), doctors notes, or test results to support a diagnosis of Alzheimers disease. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. By being in hospice, Patient 2 might not be eligible for other services. Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 2 might need. During a concurrent interview and record review on 12/14/20223, at 12:06 p.m., MD 3 reviewed Patient 2s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 4/7/2023 to 6/5/2023. The record indicated, ";Certifying Physician Summary...despite aggressive treatment, the patients condition has progressed...She does not have ability to maintain sufficient fluid and caloric intake with unintentional weight loss of 10% or more of body weight in the last six months...I attest that patient has a prognosis of six months or less if the disease runs its normal course." MD 3 stated she did not look at any medical documents because the HA did not have them, and they were in the process of getting them. MD 3 stated this was another patient they were working on discharging. The HA failed to ensure the CTI had supportive evidence of Patient 2s Alzheimers disease to validate an admission to hospice care. 3. A review of Patient 3s ";Personal Information" sheet, indicated a start of care date on 12/19/2022, with a primary diagnosis of heart failure, unspecified (heart is unable to effectively pump blood to the body). During an interview on 12/14/2023, at 9:00 a.m., Patient 3s daughter (CG 6) stated she did not know how her mother was enrolled in hospice care because she is not dying. CG 6 stated no doctor has told her and her mother Patient 3 is dying in 6 months or less. CG 6 stated her mother was no dying, ";shes just old". During a concurrent interview and record review on 12/15/2023, at 11:54 a.m., the AD/DD reviewed Patient 3s record titled, ";Comprehensive Nursing Assessment", dated 12/29/2022. The record indicated the LCD indicated Patient 3 was eligible for hospice care services because Patient 3 had been ruled out as a candidate for surgical procedures, declined surgical procedures and CHF met the criteria for NYHA class IV (4).. The AD/DD stated she did not know where the information came from. The AD/DD stated there were no medical records to support the diagnosis and findings of heart failure. The AD/DD stated the assessment was not accurate because the HA did not have supportive documents to support Patient 3s diagnosis. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. By being in hospice, Patient 3 might not be eligible for other services. Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 3 might need. During a concurrent interview and record review on 12/14/20223, at 12:09 p.m., MD 3 reviewed Patient 3s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 12/19/2022 to 2/6/2022. The record indicated, ";Certifying Physician Summary...Based on advanced heart disease she is eligible for hospice per LCD guidelines." MD 3 stated Patient 3 came from another hospice agency. If there were medical records, they should have been in her medical file. MD 3 stated she used the nursing assessment in certifying Patient 3 to hospice care. The HA failed to ensure the CTI had supportive evidence of Patient 3s heart failure to validate an admission to hospice care. 4. A review of Patient 4s ";Personal Information" sheet, indicated a start of care date on 10/19/2023, with a primary diagnosis of heart disease. During an interview on 12/14/2023, at 9:35 a.m., Patient 4 stated she learned about the HA when she visited a rehabilitation center, ";they were outside giving a flyer, I asked them if it was legal or not. They told me it was legal because its a Medicare program". Patient 4 stated she was not dying, and no doctor had told her she had 6 months or less to live. Patient 4 stated she had a primary care doctor, with the last visit being on September 30, 2023. Patient 4 stated her primary care doctor said she was okay. Patient 4 stated she was able to walk with a cane, did not need oxygen, was able to dress and shower by herself. During a concurrent interview and record review on 12/15/2023, at 11:58 a.m., the AD/DD reviewed Patient 4s record titled, ";Comprehensive Nursing Assessment", dated 10/19/2023. The record indicated the LCD indicated Patient 4 was eligible for hospice care services because Patient 4 had declined surgical procedures, was treated for heart disease with diuretics (medications that get rid of excess water in the body) and vasodilators (medications that lower the blood pressure) and CHF met the criteria for NYHA class IV (4). The AD/DD stated she did not know where the information came from. The AD/DD stated there were no medical records to support the diagnosis and findings of heart failure. The AD/DD stated the assessment was not accurate because the HA did not have supportive documents to support Patient 4s diagnosis. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. By being in hospice, Patient 4 might not be eligible for other services. Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 4 might need. During a concurrent interview and record review on 12/14/20223, at 12:13 p.m., MD 3 reviewed Patient 4s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 10/19/2023 to 1/16/2024. The record indicated, ";Certifying Physician Summary...requires moderate to maximal assistance with her ADLs (activities of daily living). She is NYHA Class IV. She has...intermittent shortness of breath at rest and with minimal movement." MD 3 stated she had not seen Patient 4 and she certified the patient ";strictly based on the nursing evaluation." The HA failed to ensure the CTI had supportive evidence of Patient 4s heart failure to validate an admission to hospice care. A review of Patient 8s medical record form titled ";Patient Information" indicated Patient 8 start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). 5.A review of Patient 8s medical record form titled ";Physicians Certification for Hospice Benefits" dated 7/15/2023 to 10/12/2023, indicated it was electronically signed by Medical Director (MD3) on 7/15/2023. A review of Patient 8s medical record titled ";Audit Log (a chronological record of system activities)" dated 7/15/2022 to 12/14/2023, indicated Medical Director 3 (MD3) signed Patient 8s CTI dated 7/15/2022 on 8/3/2022. During a joint home visit on 12/13/2023 at 10 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, Patient 8s Care Giver (CG1) stated she or Patient 8 had never been told Patient 8 had six months or less to live. CG1 stated Patient 8 is not dying. CG1 stated Patient 8 was diagnosed with diabetes (high blood sugar) about ten years ago and has been taking medications for it since. CG1 stated she was unable to speak English and required an interpreter. LVN1 called an HA interpreter to assist with translation. During a telephone interview on 12/14/2023 at 11:38 a.m. with MD3, MD3 stated Patient 8 was referred to hospice care by MD4. MD3 stated used the admitting Registered Nursing assessment to determine Patient 8 was eligible for hospice care. MD3 stated Care Giver 1 (CG1) monitors Patient 8s blood sugars. MD3 stated Patient 8s history and physical (H&P) was not uploaded into the HAs patients Electronic Medical Record (EMR). MD3 stated Receptionist 2 (RP2) should have filed Patient 8s H&P in his paper chart. 6.A review of Patient 9s medical record form titled ";Patient Information" indicated Patient 9 start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). A review of Patient 9s medical record form titled ";Physicians Certification for Hospice Benefits" dated 6/11/2023 to 9/8/2023, indicated it was electronically signed by MD3 on 7/7/2023. A review of Patient 9s medical record titled ";Audit Log" dated 6/11/2023 to 12/14/2023, indicated Registered Nurse 1 (RN1) documented under the Physician Narrative Certifying Physician Summary for Patient 9s CTI dated 6/11/2023 on 8/7/2023. It also indicated Medical Director 3 (MD3) signed Patient 9s CTI dated 6/11/2023 on 9/4/2022. During a joint home visit on 12/13/2023 at 11:45 a.m. with License Vocational Nurse 1 (LVN1) to Patient 9s home, Patient 9 noted sitting on couch in living room, got off from couch and excused herself to the restroom, then ambulated unassisted. Patient 9 stated she ambulates around her street block every day to maintain healthy. Patient 9s Care Giver (CG2) stated he or Patient 9 had never been told Patient 9 had six months or less to live. CG2 stated Patient 9 is not dying. CG2 stated Patient 9 was seen by her primary physician a month ago for her yearly physical and they stated she was doing fine. CG2 stated they were not aware Patient 9 had a hospice doctor and stated hospice doctor was not needed because she had her own. CG2 stated he speaks limited English and required an interpreter. During a telephone interview on 12/14/2023 at 11:38 a.m. with MD3, MD3 stated Patient 9 was dependent on all activities and becomes short of breath when ";moving around". MD3 stated Patient 9 was mostly in bed in November 2023. MD3 stated if she was made aware that Patient 9 was able to ambulate, she would not have certified her for hospice care. MD3 stated Patient 9s history and physical (H&P) was not uploaded into the HAs patients Electronic Medical Record (EMR). MD3 stated Receptionist 2 (RP2) should have filed Patient 9s H&P in his paper chart. 7.A review of Patient 10s medical record form titled ";Patient Information" indicated Patient 10 start of care date of 11/3/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefits" dated 11/3/2021 to 1/31/2022, indicated it was electronically signed by Registered Nurse 3 (RN3) on 11/3/2021. A review of Patient 10s medical record titled ";Audit Log" dated 11/3/2023 to 12/14/2023, indicated Registered Nurse 3 (RN3) documented under the Physician Narrative Certifying Physician Summary for Patient 10s CTI dated 11/3/2021 on 11/11/2021. 8.A review of Patient 12s medical record form titled ";Patient Information" indicated Patient 12 start of care date of 1/13/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefits" dated 1/13/2021 to 4/12/2021, indicated it was electronically signed by Medical Doctor 5 (MD5) on 1/13/2021. A review of Patient 12s medical record titled ";Audit Log" dated 1/15/2021 to 12/14/2023, indicated Medical Director 5 (MD5) signed Patient 12s CTI dated 1/13/2021 on 1/17/2021. 9.A review of Patient 14s medical record form titled ";Patient Information" indicated Patient 14 start of care date of 7/20/2023, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 14s medical record form titled ";Physicians Certification for Hospice Benefits" dated 7/20/2023 to 9/17/2022, indicated it was electronically signed by MD3 on 7/17/2023. A review of Patient 14s medical record titled ";Audit Log" dated 7/21/2023 to 12/14/2023, indicated Medical Director 1 (MD1) signed Patient 14s CTI dated 7/20/2023 on 8/1/2023. During a telephone interview on 12/14/2023 at 11:38 a.m. with MD3, MD3 stated she uses a combination of LCD guidelines and other signs and symptoms to admit patients for hospice care. MD3 stated she relies on the admitting Registered Nurse assessment to determine hospice eligibility. MD3 stated the way to comply was to review any medical record available and rely on face-to-face evaluations. MD3 stated she was behind on patients certification for terminal illness documentation. MD3 stated no one was allowed to document under patients certification for terminal illness form. MD3 stated no one had her EMR log in information. MD3 stated ";My understanding is that when they sign for hospice the services are explained already, I assume when I tell them that I am their doctor they know that I am." MD3 stated ";I rely on the hospice that the multidisciplinary team are involved, and the family understand what hospice services is. That is not under my control." MD3 stated ";The initial CTI, the first certification is the RNs evaluation." During a concurrent interview and record review on 12/14/2023 at 12:15 p.m. with the Administrator/Director of Nurses Designee (AD/DD) of HAs EMR, AD/DD stated they did not have any of the sample patients history and physical in their EMR system or in their paper charts. AD/DD stated, ";The admitting nurse responsibility is to do a patient assessment, input the information and report to the doctor and submit documentation." During an interview on 12/14/2023 at 12:45 p.m. with the AD/DD, AD/DD stated CTIs are to be signed within 48 hours of completion. AD/DD stated the physician is supposed to fill out the narrative section and sign patients CTI. A review of facilitys public brochure, undated, indicated ";Hospice Medical Director works with attending physician..." A review of facility form titled ";Employee List" undated, indicated the Volunteer Coordinator (VC) was listed ";Access Level – Admin" and ";Discipline – ADMN". A review of VCs, HA employment application dated 1/16/2023, indicated VC signed and dated form on 1/16/2023. It also indicated ";Positions applied for – Volunteer Coordinator". A record review of the HAs policy and procedure titled, ";Certification of Terminal Illness" revised 4/2019, indicated ";When certifying the patient as terminally ill, the hospice medical director must considerate least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. The certification may be completed no more that fifteen (15) calendar days prior to the effective date of the hospice election. " A record review of the HAs policy and procedure titled, ";Physician Services – Medical Director" revised 4/2019, indicated ";The duties and responsibilities of the Medical Director will include, but not be limited to, the following: Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care. Documenting care provided in the patients clinical record, providing evidence of progression of the end-stage disease process."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the medical director and/or physician designee conducted a review and verified the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, Patient 10, and Patient 12). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- 1. A review of Patient 1s ";Personal Information" sheet, indicated a start of care date of 5/9/2022, with a primary diagnosis of unspecified heart failure (heart is unable to effectively pump blood to the body). During an observation of a home visit on 12/13/2023, at 10:40 a.m., Registered Nurse 2 (RN 2) provided care to Patient 1. During an interview at the home visit on 12/13/2023, at 10:57 a.m., Patient 1s caregiver (CG 3) stated she takes Patient 1 to the mall to walk. CG 3 stated Patient 1 used a walker to walk slowly at the mall. CG 3 stated Patient 1 did not have shortness of breath when walking at the mall or when walking two blocks around her home. During an interview at the home visit on 12/13/2023, at 11:15 a.m., Patient 1 stated the HA provided oxygen to her, but she did not use it. Patient 1 stated the last time she used oxygen was six months ago when she was sick. Patient 1 stated she did not need oxygen when walking. During an interview at the home visit on 12/13/2023, at 11:44 a.m., Patient 1 stated no doctor had told her she was dying. Patient 1 stated no doctor had told her she had six months or less to live. During an interview at the home visit on 12/13/2023, at 12:00 p.m., Patient 1s daughter (CG 4) stated she did not know her mother was in hospice care. CG 4 stated her mother was not dying and thought the nurse who was visiting her was from the insurance plan, not a hospice agency. During a concurrent interview and record review on 12/14/20223, at 12:02 p.m., MD 3 reviewed Patient 1s record titled, ";Physicians Certification for Hospice Benefit" (CTI), for certification period 10/31/2023 to 12/29/2023. The record indicated, ";Certifying Physician Summary...Her symptoms are classified as NYHA class IV. Patient continues to have shortness of breath at rest and with minimal movement." MD 3 stated she asked for more information from the HA. MD 3 stated, during the face-to-face visit, Patient 1 was not on oxygen, was not feeling short of breath and her blood pressure was okay. MD 3 stated ";we were working on discharging her". During a concurrent interview and record review on 12/15/2023, at 11:44 a.m., the Administrator/Director of Nurses Designee (AD/DD) reviewed Patient 1s record titled, ";Re-Cert Assessment", dated 12/5/2023. The record indicated the LCD (Local Criteria Determination, a tool used to qualify a patient for hospice care services) indicated Patient 1 was eligible for hospice care services because Patient 1 had been ruled out as a candidate for surgical procedures and her Congestive Heart Failure (CHF, a chronic condition in which the heart doesn't pump enough blood to meet body's needs) met the criteria for NYHA (New York Heart Association-classifies the extend of heart failure) class IV (4) level (Class IV-severe limitation. Experiences symptoms even while at rest. Mostly bedbound patients.) The AD/DD stated she did not know where the information was obtained from to complete the LCD. The AD/DD stated the assessment was not accurate because the HA did not have supportive documents to support Patient 1s diagnosis. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. AD/DD stated by being in hospice, Patient 1 might not be eligible for other services. AD/DD stated Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 1 might need. A review of Patient 1s audit log (an electronic record that indicates the date and time a user made modifications to a medical record) dated 5/10/2022 to 12/14/2023, indicated MD 3 signed the CTI for period beginning on 10/31/2023 on December 7, 2023. During an interview on 12/14/2023, at 1:03 p.m., the AD/DD stated the certifying doctor is supposed to sign the CTI within 48 hours of when the patient is supposed to be certified. The importance of this timeframe was to document the reason to continue hospice services. The HA recertified Patient 1 for hospice services without having objective information about the diagnosis. MD 3 did not recertify Patient 1 within 48 hours of 10/31/2023. 2. A review of Patient 2s ";Personal Information" sheet, indicated a start of care date of 4/7/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). During an interview on 12/14/2023 at 8:55 a.m., Patient 2s daughter (CG 5) stated it was a mistake her mother was in hospice care, as she was not supposed to be in the hospice program. CG 5 stated Patient 2 was not dying, as no doctor had told her and Patient 2 she had six months or less to live. CG 5 stated she informed the HA her mother did not need hospice services, since her mother was not terminal, and has never been considered terminal. During a concurrent interview and record review on 12/15/2023, at 11:51 a.m., the AD/DD reviewed Patient 2s record titled, ";Re-Cert", dated 11/29/2023. The record indicated the LCD indicated Patient 2 was eligible for hospice care services due to inability to carry out activities of daily living and inability to maintain sufficient fluid and calorie intake with 10 percent (%, a ratio) weight loss during the previous six months. The AD/DD stated there was no documentation about Patient 2s weight or MAC (mid arm circumference, an indicator of nutritional status) to show the weight loss. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. The AD/DD stated by being in hospice, Patient 2 might not be eligible for other services. The AD/DD stated Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 2 might need. A record review of Patient 2s CTI, for certification period 12/3/2023 to 1/31/2024, indicated, ";Certifying Physician Summary...Patient has lost 2 cm (cm, a unit of measurement) in MAC since last certification. Patient continues to meet eligibility criteria for hospice." The HA recertified Patient 2 for hospice services without having objective information to support the reasons for certification. 3. A review of Patient 3s ";Personal Information" sheet, indicated a start of care date of 12/19/2022, with a primary diagnosis of unspecified heart failure (heart is unable to effectively pump blood to the body). During an interview on 12/14/2023, at 9:00 a.m., Patient 3s daughter (CG 6) stated she did not know how her mother was enrolled in hospice care because she is not dying. CG 6 stated no doctor has told her and her mother Patient 3 is dying in six months or less. CG 6 stated her mother was not dying, ";shes just old". During a concurrent interview and record review on 12/15/2023, at 11:55 a.m., the AD/DD reviewed Patient 3s record titled, ";Re-Cert Assessment", dated 12/4/2023. The record indicated the LCD indicated Patient 3 was eligible for hospice care services because Patient 3 had been ruled out as a candidate for surgical procedures, declined surgical procedures, and CHF met the criteria for NYHA class IV (4). The AD/DD stated she did not know where the information came from. The AD/DD stated there were no medical records to support the diagnosis and findings of heart failure. The AD/DD stated the assessment was not accurate because the HA did not have supportive documents to support Patient 3s diagnosis. The AD/DD stated it was important for the assessment to be accurate because the HA has to prove the patient is eligible for hospice care. The AD/DD stated by being in hospice, Patient 3 might not be eligible for other services. The AD/DD stated Medicare might not cover other services such as home health, hospitalization, or any other referrals Patient 3 might need. A review of Patient 3s CTI, for certification period 10/15/2023 to 12/13/2023, indicated, ";Certifying Physician Summary...His symptoms are classified as NYHA class IV. I attest that patient has prognosis of six months or less if the disease runs its normal course." A review of Patient 3s audit log dated 12/19/2022 to 12/14/2023, indicated MD 3 signed the CTI for period beginning on 10/15/2023 on December 7, 2023. The HA recertified Patient 3 for hospice services without having objective information about the diagnosis. MD 3 did not recertify Patient 3 within 48 hours of 10/15/2023. 4. A review of Patient 8s medical record form titled ";Patient Information" sheet, indicated Patient 8 had a start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s medical record form titled ";Physicians Certification for Hospice Benefits" dated 11/7/2023 to 1/5/2024, indicated it was electronically signed by Medical Director 3 (MD3), date of signature not documented. A review of Patient 8s medical record titled ";Audit Log" dated 7/15/2022 to 12/14/2023, indicated Medical Director 3 (MD3) signed Patient 8s CTI dated 10/13/2022 on 12/1/2022; CTI dated 1/11/2023 on 3/14/2023; CTI dated 5/11/2023 on 6/29/2023; CTI dated 7/10/2023 on 9/11/2023; CTI dated 9/8/2023 on 9/11/2023; and CTI dated 11/7/2023 on 12/7/2023. During a joint home visit on 12/13/2023 at 10:00 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, Patient 8s caregiver (CG1) stated she or Patient 8 had never been told Patient 8 had six months or less to live. CG1 stated Patient 8 is not dying. CG1 stated Patient 8 was diagnosed with diabetes (high blood sugar) about ten years ago and has been taking medications for it since. CG1 stated she was unable to speak English and required an interpreter. LVN1 called an HA interpreter to assist with translation. During a telephone interview on 12/14/2023 at 11:38 a.m. with MD3, MD3 stated Patient 8 was referred to hospice care by MD4. MD3 stated she used the admitting Registered Nursing assessment to determine Patient 8 was eligible for hospice care. MD3 stated caregiver 1 (CG1) monitors Patient 8s blood sugars. MD3 stated Patient 8s history and physical (H&P) was not uploaded into the HAs patients Electronic Medical Record (EMR). MD3 stated Receptionist 2 (RP2) should have filed Patient 8s H&P in his paper chart. 5. A review of Patient 9s medical record form titled ";Patient Information" sheet, indicated Patient 9 had a start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). A review of Patient 9s medical record form titled ";Physicians Certification for Hospice Benefits" dated 11/8/2023 to 1/6/2024, indicated it was electronically signed by MD3 on 11/2/2023. A review of Patient 9s medical record titled ";Audit Log" dated 6/11/2023 to 12/14/2023, indicated Medical Director 3 (MD3) signed Patient 9s CTI dated 9/9/2023 on 9/4/2023 and CTI dated 11/8/2023 on 12/7/2023. It also indicated the Volunteer Coordinator (VC) documented under the Physician Narrative Certifying Physician Summary for Patient 9s CTI dated 11/8/2023 on 11/2/2023. During a joint home visit on 12/13/2023 at 11:45 a.m. with License Vocational Nurse 1 (LVN1) to Patient 9s home, noted Patient 9 was sitting on the couch in the living room, then Patient 9 got off from the couch, excused herself to the restroom, then ambulated unassisted. Patient 9 stated she ambulates around her street block every day to maintain healthy. Patient 9s caregiver (CG2) stated he or Patient 9 had never been told Patient 9 had six months or less to live. CG2 stated Patient 9 is not dying. CG2 stated Patient 9 was seen by her primary physician a month ago for her yearly physical and they stated she was doing fine. CG2 stated they were not aware Patient 9 had a hospice doctor and stated hospice doctor was not needed because she had her own. CG2 stated he speaks limited English and required an interpreter. During a telephone interview on 12/14/2023 at 11:38 a.m. with MD3, MD3 stated Patient 9 was dependent on all activities and becomes short of breath when ";moving around". MD3 stated Patient 9 was mostly in bed in November 2023. MD3 stated if she was made aware that Patient 9 was able to ambulate, she would not have certified her for hospice care. MD3 stated Patient 9s history and physical (H&P) was not uploaded into the HAs patients Electronic Medical Record (EMR). MD3 stated Receptionist 2 (RP2) should have filed Patient 9s H&P in his paper chart. 6. A review of Patient 10s medical record form titled ";Patient Information" sheet, indicated Patient 10 had a start of care date of 11/3/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefits" dated 10/24/2023 to 12/22/2023, indicated it was electronically signed by MD3 on 10/17/2023. A review of Patient 10s medical record titled ";Audit Log" dated 11/3/2023 to 12/14/2023, indicated Medical Director 3 (MD3) signed Patient 10s CTI dated 8/30/2022 on 10/3/2022; CTI dated 10/29/2022 on 1/10/2022; CTI dated 2/26/2022 on 3/14/2022; CTI dated 12/28/2022 on 3/14/2022; CTI dated 4/27/2023 on 6/28/2023; CTI dated 8/25/2023 on 9/11/2023; and CTI dated 10/24/2023 on 12/7/2023. 7. A review of Patient 12s medical record form titled ";Patient Information" sheet, indicated Patient 12 had a start of care date of 1/13/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefits" dated 10/30/2023 to 12/28/2023, indicated it was electronically signed by MD3 on 10/19/2023. A review of Patient 12s medical record titled ";Audit Log" dated 1/15/2021 to 12/14/2023, indicated Medical Director 5 (MD5) signed Patient 12s CTI dated 4/13/2021 on 4/6/2021. During a telephone interview on 12/14/2023 at 11:38 a.m. with MD3, MD3 stated she uses a combination of LCD guidelines and other signs and symptoms to admit patients for hospice care. MD3 stated she relies on the admitting Registered Nurse assessment to determine hospice eligibility. MD3 stated the way to comply was to review any medical record available and rely on face-to-face evaluations. MD3 stated she was behind on patients certification for terminal illness documentation. MD3 stated no one was allowed to document under patients certification for terminal illness form. MD3 stated no one had her EMR log in information. MD3 stated, ";My understanding is that when they sign for hospice, the services are explained already, I assume when I tell them that I am their doctor, they know that I am." MD3 stated, ";I rely on the hospice that the multidisciplinary team are involved, and the family understand what hospice services is. That is not under my control." MD3 stated, ";The initial CTI, the first certification is the RNs evaluation." A review of facilitys undated public brochure, indicated ";If the patients physician and hospice medical director certify that the condition is still terminal and the patients condition is declining he or she will continue to receive hospice services." A review of facility's undated form titled ";Employee List", indicated the Volunteer Coordinator (VC) was listed ";Access Level – Admin" and ";Discipline – ADMN". A review of VC, HA employment application dated 1/16/2023, indicated VC signed and dated form on 1/16/2023. It also indicated ";Positions applied for – Volunteer Coordinator". A record review of the HAs policy and procedure titled, ";Certification of Terminal Illness" revised 4/2019, indicated ";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 patients medical record or, if applicable, examination of the patient. A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than fifteen (15) calendar days prior or two (2) calendar days after the first day of each period. The signed and dated certification must be present prior to billing for each recertification period." A record review of the HAs policy and procedure titled, ";Physician Services – Medical Director" revised 4/2019, indicated ";The duties and responsibilities of the Medical Director will include, but not be limited to, the following: Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care. Documenting care provided in the patients clinical record, providing evidence of progression of the end-stage disease process."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation on Clinical Records was met as follows: --- 1. The HA failed to ensure one of fourteen sampled patients (Patient 2) had signed notice of patient rights in their medical record. (Refer to L673). 2. The HA failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for eight of fourteen sampled patients (Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L679) 3. The HA failed to ensure contents and information in the patients medical records were safeguarded from unauthorized access by HA staff and/or contracted staff to make any alterations or modifications for fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L680). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records are safeguarded from unauthorized access by any individuals or hospice staff.

Based on interview and record review, the Hospice Agency (HA) failed to ensure one of fourteen sampled patients (Patient 2) had signed notice of patient rights in their medical record. This failure resulted in patients not being aware of their rights while receiving hospice services. --- A review of Patient 2s ";Personal Information" sheet, indicated a start of care date of 4/7/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). During an interview on 12/12/2023, at 1:35 p.m., the receptionist 2 (RP 2) stated she could not find Patient 2s admission consents for the current admission. During a concurrent observation and interview on 12/12/2023, at 1:50 p.m., RP 2 had a white-out and consents titled, ";Patient Acknowledgement", ";7 Days Hospice Care Intake Sheet" ";Polst:, dated 2/25/22", ";Decline of Specific Services", ";Release of Information & Consent for Treatment", ";Election of Medicare Hospice Benefit". RP 2 stated she had white out the previous date and documented the date ";4/7/2023" but was not going to give it to the survey team because she knew it was wrong. During a concurrent interview and record review on 12/12/2023, at 1:55 p.m., the Administrator/Director of Nurses designee (AD/DD) took Patient 2s record titled, ";Patient Acknowledgement" up against the ceiling light, and stated date ";2/25/22" was white out. The AD/DD stated the date that was manually entered over the white out was ";4/7/2023" under ";Patient/Responsible Party Signature" and ";RN Signature". During an interview on 12/12/2023, at 2:01 p.m., the AD/DD stated the Patient Acknowledgement form is the paper the patient signs to indicate the HA gave them those documents listed. The AD/DD stated there was no consents in her file for the current admission. A record review of the HAs policy and procedure titled, ";Rights/Responsibilities" dated 1995, indicated ";Each patient will be an active, informed participant in his/her plan of care. To encourage awareness of patient rights and responsibilities to provide guidelines to assess patient making decisions regarding care, and to support active participation in care planning. Upon admission, each hospice patient and/or his/her representative will be given a written copy of the Patient Rights and Responsibilities. This explanation will be in a language that the patient and manager understand." A record review of the HAs policy and procedure titled, ";Patient Bill of Rights/Responsibilities", dated 2019, indicated, ";Procedure...3. The Patient Bill of Rights/Responsibilities will 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...6C. Written information will be provided to patients in the predominant languages of the population served."

Based on interview and record review, the hospice agency (HA) failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for eight of fourteen sampled patients (Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients clinical record that could affect the patients quality of care and well-being. --- a. A review of Patient 4s ";Personal Information" sheet, indicated a start of care date of 10/19/2023, with a primary diagnosis of heart disease. During a concurrent interview and record review on 12/14/2023, at 11:30 a.m., the Administrator/Director of Nurses designee (AD/DD) reviewed Patient 4s record titled, ";Comprehensive Nursing Assessment", dated 10/19/2023. The AD/DD stated she did not know who wrote the note because the record did not indicate it. The AD/DD stated the nurse had to sign the document to prove the visit was done and the information was correct. b. A review of Patient 8s medical record form titled ";Patient Information" sheet, indicated Patient 8 had a start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). A review of Patient 8s medical record form titled ";Physicians Certification for Hospice Benefits" dated 7/15/2023 to 10/12/2023, indicated it was electronically signed by Medical Director (MD3) on 7/15/2023. A review of Patient 8s medical record titled ";Audit Log (a chronological record of system activities)" dated 7/15/2022 to 12/14/2023, indicated Medical Director 3 (MD3) signed Patient 8s CTI dated 7/15/2022 on 8/3/2022. c. A review of Patient 9s medical record form titled ";Patient Information" sheet, indicated Patient 9 had a start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). A review of Patient 9s medical record form titled ";Comprehensive Nursing Assessment" dated 6/11/2023, indicated it did not have HAs staff signature, unknown author. A review of Patient 9s medical record form titled ";Physicians Certification for Hospice Benefits" dated 6/11/2023 to 9/8/2023, indicated it was electronically signed by MD3 on 7/7/2023. A review of Patient 9s medical record titled ";Audit Log" dated 6/11/2023 to 12/14/2023, indicated Registered Nurse 1 (RN1) documented under the Physician Narrative Certifying Physician Summary for Patient 9s CTI dated 6/11/2023 on 8/7/2023. It also indicated Medical Director 3 (MD3) signed Patient 9s CTI dated 6/11/2023 on 9/4/2022. d. A review of Patient 10s medical record form titled ";Patient Information" sheet, indicated Patient 10 had a start of care date of 11/3/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefits" dated 11/3/2021 to 1/31/2022, indicated it was electronically signed by Registered Nurse 3 (RN3) on 11/3/2021. A review of Patient 10s medical record titled ";Audit Log" dated 11/3/2023 to 12/14/2023, indicated Registered Nurse 3 (RN3) documented under the Physician Narrative Certifying Physician Summary for Patient 10s CTI dated 11/3/2021 on 11/11/2021. e. A review of Patient 11s medical record form titled ";Patient Information" sheet, indicated Patient 11 had a start of care date of 10/20/2023, with diagnoses including cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). A review of Patient 11s medical record form titled ";Comprehensive Nursing Assessment" dated 10/20/2023, indicated it did not have HAs staff signature, unknown author. A review of Patient 11s medical record titled ";Audit Log" dated 12/12/2023 to 12/15/2023, indicated Volunteer Coordinator (VC) documented under ";visit note – Narrative" on 12/12/2023 for visit date of 12/11/2023. It also indicated VC also documented under ";visit note – Narrative" on 12/12/2023 for visit date of 12/4/2023. The record also indicated VC documented under ";visit note – Narrative" on 12/12/2023 for visit date of 12/1/2023. f. A review of Patient 12s medical record form titled ";Patient Information" sheet, indicated Patient 12 had a start of care date of 1/13/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefits" dated 1/13/2021 to 4/12/2021, indicated it was electronically signed by Medical Doctor 5 (MD5) on 1/13/2021. A review of Patient 12s medical record titled ";Audit Log" dated 12/12/2023 to 12/15/2023, indicated Previous Hospice Owner (PHO) documented under ";visit note – Narrative" on 12/12/2023 for visit dates 11/6/2023, 11/13/2023, 11/16/2023, 11/20/2023, 11/27/2023, 11/30/2023 and 12/1/2023. A review of Patient 12s medical record titled ";Audit Log" dated 1/15/2021 to 12/14/2023, indicated Medical Director 5 (MD5) signed Patient 12s CTI dated 1/13/2021 on 1/17/2021. g. A review of Patient 13s medical record form titled ";Patient Information" sheet, indicated Patient 13 had a start of care date of 4/1/2021, with diagnoses including malignant neoplasm (cancer) of prostate. A review of Patient 13s medical record form titled ";Comprehensive Nursing Assessment" dated 4/1/2023, indicated it did not have HAs staff signature, unknown author. A review of Patient 13s medical record form titled ";Re-Cert Assessment" dated 6/24/2023, indicated it did not have HAs staff signature, unknown author. h. A review of Patient 14s medical record form titled ";Patient Information" sheet, indicated Patient 14 had a start of care date of 7/20/2023, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 14s medical record form titled ";Physicians Certification for Hospice Benefits" dated 7/20/2023 to 9/17/2022, indicated it was electronically signed by MD3 on 7/17/2023. A review of Patient 14s medical record titled ";Audit Log" dated 12/12/2023 to 12/15/2023, indicated Registered Nurse 1 (RN1) documented under ";visit note – Narrative" on 12/14/2023 for visit dare of 8/23/2023. A review of Patient 14s medical record titled ";Audit Log" dated 7/21/2023 to 12/14/2023, indicated Medical Director 1 (MD1) signed Patient 14s CTI dated 7/20/2023 on 8/1/2023. During an interview on 12/14/2023 at 12:15 p.m. with the Administrator/Director of Nurses Designee (AD/DD), AD/DD stated responsibilities of the admitting nurse were to complete patient assessments, input the information into their EMR system, and report to the doctor. AD/DD stated the admitting nurse also documents the comprehensive nursing assessment, completes, and signs it. A review of facility's undated form titled ";Job Title/Position: Secretary/Receptionist", indicated he/she must maintain the files, supplies, and general office condition in an orderly manner. Is responsible for maintaining administrative and clerical files." A review of facility's undated form titled ";Job Title/Position: License Practical/Vocational Nurse", indicated ";Provide accurate and timely documentation of patient services to reflect the plan of care." A review of Registered Nurse 1 (RN1) forms titled ";Performance Evaluation" dated 12/14/2021, 9/26/2022, and 9/30/2021, were reviewed and signed by AD/DD. A review of the Administrator/Director of Nurses Designee (AD/DD) HA employment application dated 12/1/2023, indicated AD/DD signed and dated form on 12/1/2023. A review of facility's undated form titled ";Job Title/Position: Executive Director/Administrator (Alternate)", indicated ";Assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. A qualified administrator appointed by and reporting to the governing body is responsible for the day-to-day operations of the hospice." It also indicated it was signed by AD/DD on 12/1/2023. A review of facility's undated, form titled ";Job Title/Position: Clinical Director/Director of Patient Care Services (Alternate)", indicated ";The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements, and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy." It also indicated it was signed by AD/DD on 12/1/2023. A record review of the HAs policy and procedure titled, ";Clinical/Service Date Collection" revised 4/2019, Indicated ";Entries to the clinical/service record will be made only by organization personnel and/or by contract personnel who have a written agreement with the organization. Entries into the clinical/service record will be made on the day care/service is provided to the patient. The clinical/service note will include: signature of clinician/technician and his/her credentials. All entries will reflect the date care was provided, including the month, day, and year." A record review of the HAs policy and procedure titled, ";Person or Entity Authentication" revised 4/2019, indicated ";(HA) will maintain a documented authentication process for verifying the identity of any person or entity prior to granting them access to ePHI (electronic protected health information). (HA) will use appropriate authentication methods to confirm that only properly authenticated and authorized persons or entities access ePHI. Removing or disabling authentication credentials in ePHI systems for persons or entities that no longer require access to ePHI. Periodic validation that no redundant authentication credentials have been issued or are in use."

Based on interview and record review, the Hospice Agency (HA) failed to ensure contents and information in the patients medical records were safeguarded from unauthorized access by HA staff and/or contracted staff to make any alterations or modifications for fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients clinical record that could affect the patients quality of care and well-being. --- 1. A review of Patient 1s ";Personal Information" sheet, indicated a start of care date of 5/9/2022, with a primary diagnosis of unspecified heart failure (heart is unable to effectively pump blood to the body). 2. A review of Patient 2s ";Personal Information" sheet, indicated a start of care date of 4/7/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). 3. A review of Patient 3s ";Personal Information" sheet, indicated a start of care date of 12/19/2022, with a primary diagnosis of unspecified heart failure (heart is unable to effectively pump blood to the body). 4. A review of Patient 4s ";Personal Information" sheet, indicated a start of care date of 10/19/2023, with a primary diagnosis of heart disease. 5. A review of Patient 5s ";Personal Information" sheet, indicated a start of care date of 12/18/2020, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). 6. A review of Patient 6s ";Personal Information" sheet, indicated a start of care date of 6/3/2021, with a primary diagnosis of heart disease. 7. A review of Patient 7s ";Personal Information" sheet, indicated a start of care date of 9/14/2023, with a primary diagnosis of Alzheimers disease (memory problems affecting ability to talk and respond). The record further indicated an end of care date of 9/16/2023, due to death. 8. A review of Patient 8s medical record form titled ";Patient Information" sheet, indicated Patient 8 had a start of care date of 7/15/2022, with diagnoses including Alzheimers Disease (progressive memory loss) and atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) without angina pectoris (chest pain). During a joint home visit on 12/13/2023 at 10:00 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, greeted at door by CG1. CG1 consented to visit. CG1 stated her preferred language was Spanish for both reading and speaking. CG1 stated in Spanish, that the HA staff knew she spoke Spanish and does not know why they provided all their paperwork in English. CG1 stated she would have requested the paperwork in Spanish, but she was not aware that there were provided in Spanish. CG1 stated HA Interpreter (IP1) was at their home 10 minutes prior to our arrival and instructed her to place a no smoking sign outside Patient 8s bedroom. LVN1 called Interpreter 1 (IP1) to assist with Spanish translation during home visit. On 12/12/2023 at 2:44 p.m. IP1 was called, from number provided by LVN1, with no answer. Message with call back number left. 9. A review of Patient 9s medical record form titled ";Patient Information" sheet, indicated Patient 9 had a start of care date of 6/11/2023, with diagnoses including atherosclerotic heart disease of native coronary artery (plaque buildup in arteries) with angina pectoris (chest pain). 10. A review of Patient 10s medical record form titled ";Patient Information" sheet, indicated Patient 10 had a start of care date of 11/3/2021, with diagnoses including Alzheimers Disease (progressive memory loss). 11. A review of Patient 11s medical record form titled ";Patient Information" sheet, indicated Patient 11 had a start of care date of 10/20/2023, with diagnoses including cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain). 12. A review of Patient 12s medical record form titled ";Patient Information" sheet, indicated Patient 12 had a start of care date of 1/13/2021, with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 12s medical record titled ";Audit Log" dated 12/12/2023 to 12/15/2023, indicated Previous Hospice Owner (PHO) documented under ";visit note – Narrative" on 12/12/2023 for visit dates 11/6/2023, 11/13/2023, 11/16/2023, 11/20/2023, 11/27/2023, 11/30/2023 and 12/1/2023. 13. A review of Patient 13s medical record form titled ";Patient Information" sheet, indicated Patient 13 had a start of care date of 4/1/2021, with diagnoses including malignant neoplasm (cancer) of prostate. 14. A review of Patient 14s medical record form titled ";Patient Information" sheet, indicated Patient 14 had a start of care date of 7/20/2023, with diagnoses including Alzheimers Disease (progressive memory loss). A review of facility's undated form titled ";Employee List", indicated ";(Receptionist 1 - RP1)" name was listed as one of the HAs employees. It also indicated RP1 had ";Access level - Intake Co-Ord (coordinator)" and ";Discipline – ADMN (administration)". RP2- was listed as ";Access Level – Admin" and ";Discipline – ADMN". Lastly, it also indicated The Administrator/Director of Nurses (ADM/DON), Home Health Agency Interpreters (IP1 & IP2), and Previous Hospice Owner (PHO) were not listed on the HA employee list. During an interview on 12/14/2023 at 10:18 a.m. with Volunteer Coordinator (VC), VC stated she did not know IP1 or IP2. During an interview on 12/14/2023 at 10:18 a.m. with Receptionist 1 (RP1), RP1 stated she did not know IP1 or IP2. During an interview on 12/14/2023 at 10:18 a.m. with Receptionist 2 (RP2), RP2 stated she did not know IP1 or IP2. During an interview on 12/15/2023 at 10 a.m. with Administrator/Director of Nurses Designee (AD/DD), AD/DD stated she had never heard of IP1 or IP2. AD/DD stated she did not know who IP1 or IP2 were. During an interview on 12/15/2023 at 10:10 a.m. with LVN1, LVN1 stated she did not know who IP1 was. LVN1 stated she called the HAs number and a female answered. LVN1 stated was provided IP1s number by the female who stated to call the number if she needed a translator. LVN1 stated the female informed her that IP1 delivers patient supplies and was able to translate. During a telephone interview on 12/15/2023 at 10:14 a.m. with HAs Task Manager / 24-hour call line (TM), the HAs phone number was called. TM stated she did not know who IP1 or IP2 were. TM stated she was the 24-hour hospice line. TM stated she answered calls and redirected them to the Manager (MG). TM was requested to provide MGs phone number, but stated she did not know his number. During an interview on 12/15/2023 at 10;17 a.m. with Receptionist 2 (RP2), RP2 stated she did not know who TM or MG were. During a telephone call on 12/15/2023 at 10:26 a.m. with caregiver 1 (CG1), CG1 stated she met IP1 for the first time on 12/13/2023, when she delivered the no smoking sign for her husband. On 12/15/2023 at 2:44 p.m. IP1 was called, from number provided by LVN1, with no answer. Message with call back number left. During an interview on 12/15/2023 at 11:06 a.m. with AD/DD, AD/DD stated she did not know who IP1, IP2, or MG were. AD/DD was requested to call the HAs owner and the ADM/DON. AD/DD stated they did not answer and that she left a message to return call. During a concurrent observation and interview on 12/12/2023 at 11:24 a.m. with Receptionist 2 (RP2) at the HA, RP2 noted arriving and introducing herself as the HAs receptionist. RP2 provided copies of HAs documents. On 12/12/2023 at 4:00 p.m. Volunteer Coordinator (VC) provided sample patients documents as requested with the assistance of the RP2. During an interview on 12/14/2023 at 10:20 a.m. with RP1, RP1 was requested to provide RP2s employee file. RP1 stated RP2 did not have an employee file. During an interview on 12/11/2023 at 10:30 a.m. with the Volunteer Coordinator (VC), VC stated RP2 did not have an employee file. VC stated she worked at different agencies and asks RP2 to assist her. VC stated RP2 has access to patients Electronic Medical Record (EMR) and that she was not an employee at the HA. During an interview on 12/14/2023 at 10:40 a.m. with RP2, RP2 stated she did not have an employee file because she did not work for the HA. RP2 stated that her name appeared on the HAs EMR employee list because ";maybe" the owner inputted her information. RP2 stated she does not know how her name was listed on the list. RP2 stated the owner and VC were the only people to have her driver license and other information. A review of facility's undated form titled ";Job Title/Position: Executive Director/Administrator (Alternate)", indicated ";Assumes full legal authority and responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations, and continuous quality assessment and performance improvement. A qualified administrator appointed by and reporting to the governing body is responsible for the day-to-day operations of the hospice." It also indicated it was signed by AD/DD on 12/1/2023. A review of facility's undated form titled ";Job Title/Position: Clinical Director/Director of Patient Care Services (Alternate)", indicated ";The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. The Clinical Director/Director of Patient Care Services establishes, implements, and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy." It also indicated it was signed by AD/DD on 12/1/2023. A record review of the HAs policy and procedure titled, ";Access to Information" revised 4/2019, indicated ";Only authorized hospice personnel will have access to clinical/service, financial, administrative and personnel records. Access to patient information files will be limited to organization personnel involved in the care of the patient and may include: Office personnel having a need to know in order to perform their functions and processes..." A record review of the HAs policy and procedure titled, ";Clinical/Service Date Collection" revised 4/2019, Indicated ";Entries to the clinical/service record will be made only by organization personnel and/or by contract personnel who have a written agreement with the organization. Entries into the clinical/service record will be made on the day care/service is provided to the patient. The clinical/service note will include: signature of clinician/technician and his/her credentials. All entries will reflect the date care was provided, including the month, day, and year." A record review of the HAs policy and procedure titled, ";Safeguarding/Retrieval of Clinical Records" revised 4/2019, indicated ";The organization will safeguard the clinical/service record against loss, destruction, tampering, or unauthorized use through the development of processes, policies and procedures. The clinical/service record will be safeguarded in compliance with Health Insurance Portability and Accountability Act (HIPAA) requirements."