Every finding on record at 911 Hospice, Inc

Based on interview and record review, the Hospice Agency (HHA) failed to ensure the emergency preparedness training for all staffs was conducted at least annually. This failure had the potential to result in the hospice staffs lack of knowledge to readily and effectively respond during an emergency crisis situation. --- During a review of the agency's emergency preparedness program documentation, the agency had no documented evidence the emergency preparedness training was conducted for all staff. On 4-20-23, at 12:05 p.m., during an interview with the DPCS, he stated the agency's emergency preparedness plan is not complete and needs work. During an interview on 5/31/23 at 11:45 a.m. with office manager, she stated the agency is nonoperational during the last few weeks. She stated they have no patients and no staff since they were a defrauded by a previous employee. She stated all patients were discharged and all staff were placed on leave. She stated they are unable to do the plan of correction from the previous complaint validation survey because they dont have any funds or staff. During a review of the agency's policy entitled "Emergency Management Plan" with a revised date of November 2020, it indicated the agency will comply with all applicable, Federal, State, and local emergency preparedness program that meets those regulations. On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on observation, interview, and record review, the hospice agency failed to ensure that the Condition of Participation regarding Patients' rights was met as follows: The hospice agency, for the three (3) of six (6) sampled patients, Patient 1, Patient 5, and Patient 6, failed to ensure the information regarding patients rights were provided to the patients and caregivers in a manner that they could understand, , This deficient practice had the potential to cause miscommunication and misunderstanding, which can affect the quality of care and services provided to all the patients under the agencys care. (Refer to L 502) The cumulative effect of these systemic practices resulted in the hospice agency's failure to protect the rights for admitted patients. --- . On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on interview and record review, for three (3) of six (6) sampled patients, Patient 1, Patient 5, and Patient 6, the hospice agency failed to ensure the information regarding patients rights were provided to the patients and caregivers in a manner that they could understand. This deficient practice had the potential to cause miscommunication and misunderstanding, which can affect the quality of care and services provided to all the patients under the agencys care. --- a. On 4/18/2023, a review of Patient 1s clinical record indicated Patient 1 was admitted to the hospice agency (HA) on 3/22/23 with a primary diagnosis of Alzheimers Disease (progressive mental deterioration due to generalized degeneration of the brain). A review of the POC dated 4/18/23 indicated the Skilled Nurse was to visit Patient 1, one time per week. The Medical Social Worker (MSW) was to visit once per month and the Spiritual Counselor (SC) was to visit once per month. A review of Patient 1s patient rights consent signed on 3/22/23, the day of initial assessment indicated it was presented to the patient and caregiver in English when their primary language was Arabic. On 4/20/23 at 12:05 p.m., an interview with the Director of Patient Care Services (DPCS) was conducted in the agency conference room. The DPCS stated the agency does not have any documentation in the patient/caregivers native language. When asked, the DPCS stated an interpreter was used during home visits and with all the communication made with the patient/caregiver, however, the DPCS could not provide any documented proof. b. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of hypertensive heart disease without heart failure (heart disease). A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 1's terminal diagnosis was hypertensive heart disease without heart failure. A review of the Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 5 was alert and oriented, was ambulatory using a cane and walker, needed moderate assistance in activities of daily living except in feeding (needed minimal/supervision). Patient 5 could take approximately 40 steps before becoming exhausted and had mild dyspnea with moderate exertion. Patient 5 was not on oxygen therapy, and her oxygen saturation was 96 percent on room air. Patient 5 did not have weight loss in the past six months, had adequate fluid intake, and her membranes were moist, and Patient 5 had good skin turgor. A review of the "Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) / interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor and the volunteer service was declined. There was no indication whether the hospice aide visit was declined or not. A review of the Discharge Summary indicated Patient 5 was hospitalized on 3/31/2023, and Patient 5s care was ended on 3/31/2023. It indicated Patient 5s symptoms were well managed with the hospice interventions, medications, and a plan of care, and she remained on a steady decline during her care with the agency. On 4/20/2023, at 10:50 a.m., the Surveyor called Patient 5s number on record. Patient 5s caregiver (CG)/Family member 2 (FM2) answered the phone. During a telephone interview with Patient 5s CG/FM 2, she stated Patient 5 could not communicate with the Surveyor because Patient 5 uses a non-dominant language. FM 2 stated she was with Patient 5 when the nurse from the agency (who did not speak the language Patient 5 uses) came to the patients house on the admission date and translated to Patient 5 what the nurse said. FM 2 stated she was not aware that the hospice service was for the person whose life expectancy was less than six months and did not know what hospice meant. FM 2 stated the nurse from the agency did not explain about the hospice service and Patient 5 should have not received the hospice service because Patient 5 was not dying nor had been told that Patient 5 had six months or less to live. When FM 2 was asked whether she was informed about Patient 5 facing possible limitations of existing medical service when enrolling in hospice, FM2 stated she was not informed. When asked whether the agency had provided Patient 5 the written notice of ";Patient Rights" and responsibilities in a language that Patient 5 could understand, she stated ";No." A review of the ";Hospice Admission Services Agreement" dated 10/20/2023 (was written in the dominant language, not written in the language Patient 5 uses), indicated Patient 5s signature. However, there was no documented evidence in the clinical record that Patient 5 was provided ";Hospice Admission Services Agreement" written in the language that Patient 5 could understand. A review of the ";Patient/Family Bill of Right" dated 10/20/2022 indicated Patient 5 signature. However, there was no documented evidence ";Patient/Family Bill of Right" was provided written in the language that Patient 5 could understand. c. A review of Patient 6's (Patient 6 was Patient 5s family member) electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of Atherosclerotic heart disease of native coronary artery. A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was hypertensive heart disease without heart failure. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 6 was alert and oriented, was ambulatory without using a cane and walker, needed minimal supervision for all activities of daily living (ADL) but needed moderate assistance in toileting. Patient 6 has shortness of breath (SOB) after moderate activity. Patient 6 was not on oxygen therapy, and his oxygen saturation was 98 percent on room air. Patient 5 did not have significant weight loss in the past six months. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor, the hospice aide service, and the volunteer service was declined. A review of the Discharge Summary indicated Patient 6 was hospitalized on 3/31/2023, and Patient 6s care was ended on 3/31/2023. It indicated Patient 6s symptoms were well managed with the hospice interventions, medications, and a plan of care, and remained on a steady decline during his care with the agency. On 4/20/2023, at 10:50 a.m., the Surveyor called Patient 6s number on record. Patient 6s CG/FM2 answered the phone call. During a telephone interview with Patient 6s CG/FM 2, she stated Patient 6 could not communicate with the Surveyor because Patient 6 uses a non-dominant language. FM 2 stated she was with Patient 6 when the nurse from the agency (who did not speak the language Patient 6 uses) came to the patients house on the admission date and translated to Patient 6 what the nurse had said. FM 2 stated she was not aware that the hospice service was for a person whose life expectancy was less than six months and did not know what hospice meant. FM 2 stated the nurse from the agency did not explain about the hospice service and Patient 6 should have not received the hospice service because Patient 6 was not dying nor had been told that Patient 6 had six months or less to live. When FM 2 was asked whether she was informed about Patient 6 facing possible limitations of existing medical service when enrolling in hospice, FM2 stated she was not informed. When asked whether the agency had provided Patient 6 the written notice for ";Patient Rights and Responsibilities" in a language that Patient 6 could understand, she stated ";No." A review of the ";Hospice Admission Services Agreement" dated 10/20/2023 (was written in the dominant language, not written in the language Patient 6 uses), indicated Patient 6s signature. However, there was no documented evidence in the clinical record that Patient 6 was provided ";Hospice Admission Services Agreement" written in the language that Patient 6 could understand. A review of the ";Patient/Family Bill of Right" (written in dominant language) dated 10/20/2022 indicated Patient 6signature. However, there was no documented evidence written ";Patient/Family Bill of Right" was provided in the language that Patient 6 could understand. On 4/20/2023, at 12:10 p.m., during an interview with the Director of Patient Care Services (DPCS) after he spoke to RN 1 (who admitted Patient 5 and Patient 6) over the phone, the DPCS stated RN 1 told him that RN 1 could not speak the language that Patient 5 and Patient 6 uses. RN 1 told the DPCS that he did not provide the ";Hospice Admission Services Agreement" and ";Patient/Family Bill of Right" written in the language that Patient 5 and Patient 6 could understand. The DPCS was unable to provide documented evidence the agency had provided ";Hospice Admission Services Agreement" and ";Patient/Family Bill of Right" written in a language that Patient 5 and Patient 6 could understand. During an interview on 5/31/23 at 11:45 a.m. with office manager, she stated the agency is nonoperational during the last few weeks. She stated they have no patients and no staff since they were a defrauded by a previous employee. She stated all patients were discharged and all staff were placed on leave. She stated they are unable to do the plan of correction from the previous complaint validation survey because they dont have any funds or staff. A review of the agencys policy and procedure titled, ";Patient Bill of Right/Responsibilities" revised in November 2020 indicated that upon admission, the admitting clinician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights/Responsibilities in advance of furnishing care. The Patient Bill of Right/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 review of the agencys policy and procedure titled ";Informed Consent/Refusal of Treatment" revised in November 2020 indicated upon admission and throughout the course of care/service, the patient and family/caregiver will be given information in an understandable language to make decisions regarding the care and services being provided. On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of Patients was met as followed: --- The hospice agency failed to determine the patient's eligibility for hospice care and services and failed to identify the terminal illness that met the criteria for hospice care and services, for the three of six sampled patients (Patient 1, Patient 5 and Patient 6). This deficient practice resulted in patients ineligible for hospice care were enrolled under hospice care, which can affect the quality of life, and in maintaining their highest practicable physical, mental and psychosocial wellbeing. (Refer to L 524). The cumulative effects 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 benefits. On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on observation, interview and record review, the hospice agency failed to determine the patient's eligibility for hospice care and services and failed to identify the terminal illness that met the criteria for hospice care and services, for the three of six sampled patients (Patient 1, Patient 5 and Patient 6). This deficient practice resulted in patients ineligible for hospice care were enrolled under hospice care, which can affect the quality of life, and in maintaining their highest practicable physical, mental and psychosocial wellbeing. --- a. On 4/18/23 at 12 p.m., during a clinical record review, Patient 1s clinical record indicated Patient 1 was admitted to the hospice agency (HA) on 3/22/23 with a primary diagnosis of Alzheimers Disease (progressive mental deterioration due to generalized degeneration of the brain). A review of the plan of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 4/18/23 indicated the Skilled Nurse to visit Patient one time per week. The Medical Social Worker (MSW) to visit once a month, and the Spiritual Counsellor (SC) to visit once a month. A review of the agencys document titled, ";face to face encounter" dated 3/15/23 indicated Patient 1 weighed 199 pounds (lbs). A review of the agencys document titled, ";comprehensive nursing assessment", dated 3/22/23 indicated Patient 1 weighed 133lbs. On 4/20/2023 at 12:05 p.m., an interview was conducted in the agency conference room with the Director of Patient Care Services (DPCS), the DPCS stated the history and physical, dated 3/15/23, documented a weight of 199 lbs. for Patient 1 and was not the same with the initial assessment, dated 3/22/2023, that documented a weight of 133 lbs. DPCS stated this assessment of weight was not correct. b. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of hypertensive heart disease without heart failure. It was indicated in the face sheet that Physician 2 was the referring doctor. A review of the Comprehensive Nursing Assessment (as assessment conducted by a Registered Nurse and is based on a physical assessment of the individual and a review of the individual's medical records, including physician notes, lab results and all other pertinent clinical records) by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 5 was alert and oriented, was ambulatory using a cane and walker, needed moderate assistance in the activities of daily living except in feeding (needed minimal/supervision). Patient 5 could take approximately 40 steps before becoming exhausted and had mild dyspnea with moderate exertion. Patient was not on oxygen therapy, and her oxygen saturation was 96 percent in room air. Patient 5 did not have weight loss in the past 6 months, had adequate fluid intake, and her membrane was moist and had good turgor. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week, the Registered Nurse (RN) and the medical social worker (MSW)visit was once a month. The Spiritual counselor and the volunteer service was declined. There was no indication whether the hospice aide visit was declined or not. A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination, an assessment to determine patient's eligibility for hospice services) of "Heart Disease," dated 10/20/2022, indicated that the sections for "untreatable condition" and "New York Heart Association (NYHA, classification provides a simple way of classifying the extent of heart failure), classification" must be met to determine patient's eligibility for hospice services. The form indicated that Patient 5 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record for Patient 5 indicated there was no documentation supporting Patient 5 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level". The clinical record indicated there was no documented evidence Patient 5 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," (the document that showed a physician certified a patient's eligibility for hospice benefit) for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 5's terminal diagnosis was hypertensive heart disease without heart failure. It indicated Patient 5 was alert and oriented, ambulatory with walker or a cane, could take approximately 40 steps before becoming exhausted and becomes SOB with moderate exertion. Patient 5s oxygen saturation was 96 percent in room air. Patient 5 did not have weight loss in the past 6 months, had adequate fluid intake, and her membrane was moist and had good turgor. It indicated Patient 5 met the criteria for LCD eligibility and the Medical Director had certified that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of the Discharge Summary indicated Patient 5 was hospitalized on 3/31/2023, and Patient 5s care was ended on 3/31/2023. It indicated Patient 5s symptoms were well managed with the hospice interventions, medications, and a plan of care, and she was remained on a steady decline during her care with the agency. On 4/20/2023, at 10:50 a.m., the Surveyor called Patient 5s phone number on record, Patient 5s caregiver (CG)/Family member 2 (FM2) answered the phone call. During the telephone interview, Patient 5s CG/FM 2 stated Patient 5 could not communicate with the Surveyor because Patient 5 uses non dominant language. FM 2 stated she was not aware that the hospice service was for the person whose life expectancy was less than 6 months and did not know what the hospice meant. FM 2 stated Patient 5 should have not received the hospice service because Patient 5 was not dying nor had been told that Patient 5 had 6 months or less to live. FM 2 stated Physician 1 was Patient 6's primary doctor, and she did not know who Physician 2 was. On 4/19/2023, at 12 p.m., during a telephone interview with Physician 1, who had been the primary physician of Patient 5 since 7/9/2014,Physician 1 stated she had not referred Patient 5 to the agency because Patient 5 did not have a terminal illness and was not eligible to receive hospice service. Physician 1 stated nobody from the hospice agency had communicated with her regarding Patient 5s enrollment to the agency, and she did not know Patient 5 had enrolled in the hospice agency. Physician 1 stated She had not communicated with Physician 2 and she did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at 12:15 p.m., he stated he was not able to find the documented evidence Patient 5 met the criteria for LCD eligibility, and the supporting documentation that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course, such as test result, and the consultation from Patient 5s primary care physician. The DPCS stated Physician 2 was a "Mobile doctor." During a telephone interview with the current Medical Director (MD) on 4/20/2023, at 12:48 p.m., she stated she became the Medical Director of the hospice agency less than a month ago. The MD stated when the agency admits the patient to the hospice agency, the MD/NP should see the patient (physically or facetime), interview family and patient, communicate with the patients primary physician and review the history and physical from the patients primary physician, review the hospital record (if any), and review the RNs assessment and LCD assessment. c. A review of Patient 6's (Patient 6 was Patient 5s family member) electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery. The face sheet indicated that Physician 2 was the referring doctor. A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was hypertensive heart disease without heart failure. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 6 was alert and oriented, was ambulatory without using a cane and walker, needed minimal supervision for all activities of daily living (ADL) but needed moderate assistance in toileting. Patient 6 had shortness of breath (SOB) after moderate activity. Patient 6 was not on oxygen therapy, and his oxygen saturation was 98 percent on room air. Patient 6 did not have significant weight loss in the past six months. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor, the hospice aide service, and the volunteer service was declined. A review of the form titled, "LCD Hospice Eligibility Determination" of "Heart Disease," dated 10/20/2022, indicated the sections for "Untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine the patient's eligibility for hospice services. The form indicated Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation to support Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level." A review of the clinical record indicated there was no documented evidence Patient 6 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," for the first 90-day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was atherosclerotic heart disease of native coronary artery. It indicated Patient 6 was alert and oriented, ambulatory without need of walker or a cane, and became short of breath with moderate exertion. Patient 6s oxygen saturation (oxygen level in the blood, with normal range of 95-100%) was measured as 98 percent on room air. Patient 6 did not have significant weight loss in the past six months. It also indicated Patient 6 met the criteria for LCD eligibility, and the Medical Director had certified that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. On 4/20/2023, at 10:50 a.m., when the Surveyor called Patient 6s number of record, Patient 6s caregiver (CG)/Family member 2 (FM2) answered the phone call. During a telephone interview with Patient 6s CG/FM 2, she stated Patient 6 could not communicate with the Surveyor because Patient 5 uses non dominant language. FM 2 stated she was not aware the hospice service was for the person whose life expectancy was less than six months, and did not know what the hospice meant. FM 2 stated she was told the hospice service was provided at home instead of the patient going to other place to receive care. FM 2 stated Patient 6 should have not received the hospice service because Patient 6 was not dying nor had been told that Patient 6 had 6 months or less to live. FM 2 stated Physician 1 was Patient 6's primary doctor, and she did not know who Physician 2 was. A review of the Discharge Summary indicated Patient 6 was hospitalized on 3/31/2023, and Patient 6s care was ended on 3/31/2023. It indicated Patient 6s symptoms were well managed with the hospice interventions, medications, and a plan of care, and she was remained on a steady decline during his care with the agency. On 4/19/2023, at12 p.m., during a telephone interview with Physician 1 who had been a primary physician (PCP) of Patient 6 since 8/9/2017, Physician 1 stated she had not referred Patient 6 to the agency because Patient 6 did not have a terminal illness and was not eligible to receive hospice service. PCP 1 stated nobody from the hospice agency had communicated with her regarding Patient 6s enrollment to the agency, and she did not know Patient 6 had enrolled with the hospice agency. Physician 1 stated she had not communicated with Physician 2 and she did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at12:15 p.m., he stated he was not able to find the documented evidence Patient 6 met the criteria for LCD eligibility, and the supporting documentation that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course (such as test result, and the consultation from Patient 6s primary care physician). The DPCS stated Physician 2 was a "Mobile doctor." There was a ";Termination Agreement" signed by the previous Medical Director which indicated the previous Medical Director would terminate the ";Professional Services Agreement, Medical Director" as of March 5, 2023. During a telephone interview with the current Medical Director (MD) on 4/20/2023, at 12:48 p.m., she stated she became a Medical Director of the hospice agency less than a month ago. The MD stated when the agency admits a patient to the hospice agency, the MD/NP should see the patient (physically or via facetime), interview family and patient, communicate with the patients primary physician and review the history and physical from the patients primary physician, review the hospital record (if any), review the RNs assessment and LCD assessment. A review of the agencys policy titled ";Admission Criteria and Process", revised November 2020 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). The policy also indicated the agency will admit a patient only on recommendation of the medical director in consultation with or input from, the patients attending physician, if any. 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. A review of the agencys policy and procedure titled ";Certification of Terminal Illness" revised in November 2020 indicated as follows: At the time of admission to hospice, the hospice Medical Director or the patients attending physician will complete a certification narrative that reflects the patients individual circumstances based on: his/her review of the patients medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms). During an interview on 5/31/23 at 11:45 a.m. with office manager, she stated the agency is nonoperational during the last few weeks. She stated they have no patients and no staff since they were a defrauded by a previous employee. She stated all patients were discharged and all staff were placed on leave. She stated they are unable to do the plan of correction from the previous complaint validation survey because they dont have any funds or staff. On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met by failing to: 1. Ensure that the interdisciplinary group [IDG, team members from different disciplines,(physician, a registered nurse (RN), a social worker (SW), and a pastor or spiritual counselor), who are working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were attended by the team to discuss the patient's plan of care and progress for six of six sampled patients, (Patients 1, 2, 3, 4, 5, 6). This deficient practice had the potential that patients care needs are not assessed and addressed timely that can affect the quality of care necessary to maintain the highest practicable physical, mental, and psychosocial well-being of the patients under the agencys care. (Refer to L541). 2. Ensure the plan of care was followed and revised regarding the use of oxygen, to relieve the difficulty in breathing for one of six sampled patients, (Patient 4). This deficient practice can result in the agency not providing appropriate patient care and services necessary to maintain the patient's highest practicable well-being. (Refer to L 553). 3. Ensure oxygen supply was coordinated with the hospice agency personnel and failed to ensure the oxygen was available and accessible at home in case of respiratory distress, for one of six sampled patients, Patient 1. This deficient practice placed Patient 1 at risk for respiratory distress and discomfort when a respiratory crisis occurs. (Refer to L555). 4. Ensure abnormal vital signs (blood pressure, heart rate, respiratory rate, temperature), for one of six sampled patients (Patient 2) were reported to the physician as per (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers). This deficient practice had the potential to result in complications and delayed interventions when abnormal vital signs are not reported to the physician timely. (Refer to L 557). 5. 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), including the Medical Director, communicated with the patient's' primary care physician to verify the patient's hospice care eligibility, for two of six sampled patients (Patient 5, 6). This deficient practice resulted in certifying patients for hospice (terminally ill patients with 6 months or less to live) services without clinical evidence and documentation to support the diagnoses and provided hospice care and services to patients who were not hospice qualified. (Refer to L 558). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care is provided to the patients accurately assessed to receive hospice care and services. On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on interview and record review, the hospice agency failed to ensure that the interdisciplinary group [IDG, team members from different disciplines,(physician, a registered nurse (RN), a social worker (SW), and a pastor or spiritual counselor), who are working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were attended by the team to discuss the patient's plan of care and progress for six of six sampled patients, (Patients 1, 2, 3, 4, 5, 6). This deficient practice had the potential that patients care needs are not assessed and addressed timely that can affect the quality of care necessary to maintain the highest practicable physical, mental and psychosocial well-being of the patients under the agencys care. --- a. On 4/18/2023, a review of Patient 1s clinical record indicated Patient 1 was admitted to the hospice agency (HA) on 3/22/23 with a primary diagnosis of Alzheimers Disease (progressive mental deterioration due to generalized degeneration of the brain). A review of the Plan of Care (POC) dated 4/18/23 indicated a Skilled Nurse was to visit Patient 1, one time per week. The Medical Social Worker (MSW) to visit one time per month, and Spiritual Counsellor (SC) to visit one time a month. b. On 4/18/2023, a review of Patient 2's clinical record indicated Patient 2 was admitted to the hospice agency (HA) on 10/14/22 with a primary diagnosis of hypertensive heart disease (thickening of the blood vessel walls). A review of the POC dated 4/18/2023 indicated the skilled nurse was to visit Patient 2 one time per week. A Home Health Aide (HA) was to visit one time per week and the MSW to visit one time per month c. On 4/19/2023 a review of Patient 3s clinical record indicated Patient 3 was admitted to the hospice agency (HA) on 10/14/22 with a primary diagnosis of hypertensive heart disease (thickening of the blood vessel walls). A review of the POC dated 4/18/23 indicated the skilled nurse was to visit Patient 3 one time per week, and the MSW to visit once a month. d. A review of Patient 4's clinical record indicated a start of care (SOC) date of 12/12/2022, with a primary diagnosis of atherosclerotic heart disease of native coronary artery. A review of Patient 4's POC dated 12/12/2022, indicated the Registered Nurse (RN) frequency of visits to Patient 4 is every 14 days or sooner. The Licensed Vocational Nurse (LVN) visits were to take place once per week. The Medical Social Worker (MSW) and Spiritual Counsellor (SC) visits were to be done for an initial evaluation then once a month. A review of Patient 4's "POC/IDG Review" indicated the spaces for signatures of the medical Director (MD), RN, and the MSW were left blank on 12/26/2022, 1/9/2023, 1/23/2023, 2/6/2023, 2/20/2023 and 3/6/2023. A review of Patient 4's "POC/IDG Review" indicated the spaces for signatures of the MD and the MSW were left blank on 12/12/2022 and 3/20/2023. A review of Patient 4's "POC/IDG Review" indicated the spaces for signatures of the medical Director, RN, SC, and the MSW were left blank on 4/3/2023. e. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of hypertensive heart disease without heart failure. A review of the "POC/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the LVN visit frequency was once a week. The RN and the MSW visit was once a month. The SC and the volunteer service was declined. There was no indication whether the hospice visit was declined or not. A review of the "POC/IDG Review," indicated the spaces for signatures of the MD and the MSW were left blank on 10/20/2022, 10/31/2022, and 3/31/2023. A review of the "POC/IDG Review," indicated the spaces for signatures of the MD, RN, and the MSW were left blank on 11/14/2022, 11/28/2022, 12/12/2022, 12/26/2022, 1/9/2023, 1/23/2023, 2/6/2023, 2/20/2023, 3/6/2023 and 3/20/2023. f. A review of Patient 6's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (heart disease). A review of the "POC/IDG Review," dated 10/31/2022, indicated LVN visit frequency was once a week. The RN and the MSW visit was once a month. The SC, the hospice aide service, and the volunteer service was declined. A review of the "POC/IDG Review," indicated the spaces for signatures of the MD and the MSW were left blank on 10/20/2022 and 3/20/2023. A review of the "POC/IDG Review," indicated the spaces for signatures of the MD, RN, and the MSW were left blank on 10/31/2022, 11/14/2022, 11/28/2022, 12/12/2022, 12/26/2022, 1/9/2023, 1/23/2023, 2/6/2023, 2/20/2023 and 3/6/2023. On 4/20/2023 at 12:05 p.m., an interview was conducted in the agency conference room, with Director of Patient Care Services (DPCS), he stated 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) should be signed by the participating staff, however, the IDG form was not signed. The DPCS stated if its not signed, it's like it was never done. In a further interview with the DPCS on 4/20/2023, at 12:25 p.m., he was not able to provide the documented evidence the above disciplines had participated in the IDG meeting on above days. The DPCS stated the IDG team meeting should have been held with the participation of all the IDG members (MD, RN, MSW and SC) even though the patient had refused any of above service. A review of the agency's policy titled "Interdisciplinary Group Membership and Responsibilities" revised in November 2020 indicated the Interdisciplinary group responsibilities include participation in the establishment of the plan of care for each patient admitted to the hospice service and participation in the periodic review and updating of the plan of care for each patient receiving hospice services. During an interview on 5/31/23 at 11:45 a.m. with office manager, she stated the agency is nonoperational during the last few weeks. She stated they have no patients and no staff since they were a defrauded by a previous employee. She stated all patients were discharged and all staff were placed on leave. She stated they are unable to do the plan of correction from the previous complaint validation survey because they dont have any funds or staff. On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on observation, interview and record review, the hospice agency failed to ensure the plan of care was followed and revised regarding the use of oxygen to relieve the difficulty in breathing for one of six sampled patients, (Patient 4). This deficient practice can result in the agency not providing appropriate patient care and services necessary to maintain the patient's highest practicable well-being. --- A review of Patient 4's clinical record indicated a start of care (SOC) date of 12/12/2022, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (heart disease). A review of the Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) dated 12/12/2022, indicated Patient 4 was alert and oriented, ambulatory with a cane and a walker, and needed moderate to maximal assistance for the activities of daily living (ADL). Patient 4 had moderate dyspnea at rest and an oxygen saturation (oxygen level in the blood, normal range of 95-100%) rate measured as 94 percent with two liters of oxygen being administered. A review of Patient 4's Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/ Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 12/12/2022, indicated the Registered Nurse (RN) frequency of visits to Patient 4 was for every 14 days or sooner. The Licensed Vocational Nurse (LVN) visits were once per week and the Medical Social Worker (MSW) and Spiritual Counsellor (SC) visits were on initial evaluation then once a month. There was a plan of care developed for the impaired respiratory function related to bronchospasm and airway inflammation as manifested by shortness of breath. One of the interventions indicated was to administer oxygen at two liters per minute. On 4/19/2023, at 10 a.m., during a joint home visit at Patient 4s residence with the Director of Patient Care Services (DPCS), Patient 4 was alert and oriented, and able to communicate well. Patient 4 was receiving oxygen at three point five (3.5) liters per minute via nasal cannula. At 10:05 a.m., after the DPCS checked the patients oxygen saturation, he stated it was 94 percent. During an interview with Patient 4, he stated he had been using oxygen at 3.5 liters per minute 18 hours a day for few months because two liters per minute was not enough for his dyspnea. A review of the POC/IDG from 12/12/2022 to 4/17/2023 indicated there was no documented evidence the IDG team had discussed Patient 4s oxygen administration of 2 liters per minute being not enough nor a revision of the POC. During an interview with the DPCS on 4/20/2023, at 12:25 a.m., he stated the SN should have notified the MD/IDG team about the patients use of oxygen at 3.5 liters per minute, and the plan of care should have been revised accordingly after discussion between the IDG members. A review of the agencys policy and procedure titled ";The Plan of Care" revised in November 2020 indicated the plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver based on ongoing comprehensive assessments of the patient and family/caregiver. During an interview on 5/31/23 at 11:45 a.m. with office manager, she stated the agency is nonoperational during the last few weeks. She stated they have no patients and no staff since they were a defrauded by a previous employee. She stated all patients were discharged and all staff were placed on leave. She stated they are unable to do the plan of correction from the previous complaint validation survey because they dont have any funds or staff. On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on observation, interview and record review, the hospice agency failed to ensure the oxygen supply was coordinated with the hospice agency personnel, and failed to ensure the oxygen was available and accessible at home in case of respiratory distress, for one of six sampled patients, Patient 1. This deficient practice placed Patient 1 at risk for respiratory distress and discomfort when a respiratory crisis occurs. --- On 4/18/2023, a review of Patient 1s clinical record indicated Patient 1 was admitted to the hospice agency (HA) on 3/22/23 with a primary diagnosis of Alzheimers Disease (progressive mental deterioration due to generalized degeneration of the brain). A review of the POC dated 4/18/23 indicated the Skilled Nurse was to visit Patient 1 once per week. The Medical Social Worker (MSW0 was to visit once a month, and the Spiritual Counsellor (SC) was to visit once a month. On 4/19/2023 at 10:30 a.m., an interview was conducted with Registered Nurse (RN) 1 outside of Patient 1s home. RN1 stated the oxygen concentrator was ordered for Patient 1 but is not currently in his home. RN 1 stated it should have been here and I need to follow up with the Director of Patient Care Services (DPCS). RN 1 admitted that this issue was not communicated with DPCS and RN 1 will follow up. During an interview on 4/20/2023 at 12:05 p.m., the DPCS stated the oxygen concentrator for Patient 1 was not available in the patients home, as ordered. RN 1 also that the oxygen concentrator should have been with Patient 1 in case of respiratory distress and Patient 1 will have an immediate access of the oxygen During an interview on 5/31/23 at 11:45 a.m. with office manager, she stated the agency is nonoperational during the last few weeks. She stated they have no patients and no staff since they were a defrauded by a previous employee. She stated all patients were discharged and all staff were placed on leave. She stated they are unable to do the plan of correction from the previous complaint validation survey because they dont have any funds or staff. On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on interview and record review, the hospice agency failed to ensure abnormal vital signs (blood pressure, heart rate, respiratory rate, temperature), for one of six sampled patients (Patient 2) were reported to the physician as per plan of care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers). This deficient practice had the potential to result in complications and delayed interventions when abnormal vital signs are not reported to the physician timely. --- On 4/18/2023, during a review of the clinical record for Patient 2s, the clinical record indicated Patient 2 was admitted to the hospice agency (HA) on 10/14/22 with a primary diagnosis of hypertensive heart disease (thickening of the blood vessel walls). A review of the Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) / interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) review dated 10/14/22 indicated the Skilled Nurse would visit one time per week. It also indicated to report systolic blood pressure outside of the following ranges 160-90 mmHg and diastolic blood pressures (the second number, that measures the pressure in the arteries when the heart rests between beats) .of 90–50 mmHg. A review of Patient 2s visit notes on the following dates: 12/2/22, 12/9/22, 12/23/22, 1/4/23, 2/2/23, 2/9/23, 2/16/23, and 2/20/23, indicated the diastolic blood pressure for Patient 2 was below the reportable range. --MD ORDER?--- There was no documented evidence provided to indicate the medical director (MD) was notified. On 4/20/2023 at 12:05 p.m., an interview was conducted in the agency conference room with THE Director of Patient Care Services (DPCS). The DPCS stated the MD ordered to report vital signs outside of normal parameters, which was not done. When asked, the DPCS stated there was no documentation that the vital signs were ever reported to the MD. During a review of the agencys policy titled, ";Monitoring patients response/reporting to physician", revised November 2020, indicated clinicians will monitor, document, and report the patients response to care and treatment provided on each hospice visit. Clinicians will establish and maintain ongoing communication with the patients physician and the hospice medical director to ensure safe and appropriate care for the patient. .On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on interview and record review, the hospice agency 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), including the Medical Director, communicated with the patient's' primary care physician to verify the patient's hospice care eligibility, for two of six sampled patients (Patient 5, 6). This deficient practice resulted in certifying patients for hospice (terminally ill patients with 6 months or less to live) services without clinical evidence and documentation to support the diagnoses, and provided hospice care and services to patients who were not hospice qualified. --- a. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of hypertensive heart disease without heart failure (heart disease). A review of the Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 5 was alert and oriented, was ambulatory using a cane and walker, needed moderate assistance in the activities of daily living except in feeding (needed minimal/supervision). Patient 5 could take approximately 40 steps before becoming exhausted and had mild dyspnea with moderate exertion. Patient 5 was not on oxygen therapy, and her oxygen saturation was 96 percent on room air. Patient 5 did not have weight loss in the past six months, had adequate fluid intake, and her membrane was moist and Patient 5 had fairly good skin turgor. A review of the "Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) / Interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker (MSW) visit was once a month. The Spiritual counselor (SC) and the volunteer service was declined. There was no indication whether the hospice aide visit was declined or not. A review of the form titled, "LCD Hospice Eligibility Determination" (LCD, Local Coverage Determination, an assessment to determine patient's eligibility for hospice services) of "Heart Disease," dated 10/20/2022, indicated the sections for "Untreatable condition" and "New York Heart Association Classification (NYHA, classification that provides a simple way of classifying the extent of heart failure) must be met to determine patient's eligibility for hospice services. The form indicated Patient 5 met the criteria for "Untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV, patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation supporting Patient 5 met the criteria for "Untreatable condition" and "NYHA classification" for "NYHA Class IV level". A review of the clinical record indicated there was no documented evidence Patient 5 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," (the document showed a physician certified a patient's eligibility for hospice benefit) for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 5's terminal diagnosis was hypertensive heart disease without heart failure. It indicated Patient 5 was alert and oriented, ambulatory with walker or a cane, could take approximately 40 steps before becoming exhausted and becomes SOB with moderate exertion. Patient 5s oxygen saturation was 96 percent on room air. Patient 5 did not have weight loss in the past six months, had adequate fluid intake, and her membrane was moist and had fairly good turgor. A review of the Discharge Summary indicated Patient 5 was hospitalized on 3/31/2023, and Patient 5s care was ended on 3/31/2023. The summary indicated Patient 5s symptoms were well managed with the hospice interventions, medications and a plan of care, and remained with a steady decline during her care with the agency. On 4/20/2023, at 10:50 a.m., the Surveyor called Patient 5s number on record and Patient 5s caregiver (CG)/Family member 2 (FM2) answered the phone call. During the telephone interview, Patient 5s CG/FM 2 stated Patient 5 could not communicate with the Surveyor because Patient 5 uses non dominant language. FM 2 stated she was not aware that the hospice service was for the person whose life expectancy was less than six months and did not know what hospice meant. FM 2 stated Patient 5 should have not received the hospice service because Patient 5 was not dying nor had been told that Patient 5 had six months or less to live. On 4/19/2023, at 12 p.m., during a telephone interview with Physician 1 who had been Patient 52 primary physician (PCP) since 7/9/2014, Physician 1 stated she did not refer Patient 5 to the hospice agency because Patient 5 did not have any terminal illness and was not eligible to receive hospice services. PCP 1 also stated, nobody from the hospice agency had communicated with her regarding Patient 5s enrollment to the hospice agency, nor she did know Patient 5 had been enrolled with the hospice agency. Physician 1 stated she had not communicated with Physician 2 and did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at12:15 p.m., the DPCS stated he was not able to find the documented evidence Patient 5 met the criteria for LCD eligibility, and any supporting document that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course, such as test result, and the consultation from Patient 5s primary care physician. b. A review of Patient 6's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (heart disease). A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was atherosclerotic heart disease. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 6 was alert and oriented, was ambulatory without using a cane and walker, needed minimal supervision for all activities of daily living (ADL) but needed moderate assistance in toileting. Patient became to have shortness of breath (SOB) after moderate activity. Patient 6 was not on oxygen therapy, and his oxygen saturation was measured as 98 percent on room air. Patient 6 did not have significant weight loss in the past six months. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor, the hospice aide service, and the volunteer service was declined. A review of the form titled, "LCD Hospice Eligibility Determination" of "Heart Disease," dated 10/20/2022, indicated that the sections for "Untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV, patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation to support Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level". A review of the clinical record indicated there was no documented evidence Patient 6 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," (the document that showed a physician certified a patient's eligibility for hospice benefit) for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 5's terminal diagnosis was hypertensive heart disease without heart failure. It indicated Patient 6 was alert and oriented, ambulatory without need walker or a cane, becomes SOB with moderate exertion. Patient 6s oxygen saturation was 98 percent on room air. Patient 6 did not have significant weight loss in the past six months. It also indicated the Medical Director had certified that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. On 4/20/2023, at 10:50 a.m., the Surveyor called Patient 6s phone number on record. Patient 6s caregiver (CG)/Family member 2 (FM2) answered the phone call. During a telephone interview with Patient 6s CG/FM 2, she stated Patient 6 could not communicate with the Surveyor because Patient 5 uses a non-dominant language. FM 2 stated she was not aware that the hospice service was for the person whose life expectancy was less than six months and did not know what the term hospice meant. FM 2 stated Patient 6 should have not received the hospice service because Patient 6 was not dying nor had been told Patient 6 had six months or less to live. A review of the Discharge Summary indicated Patient 6 was hospitalized on 3/31/2023, and Patient 6s care was ended on 3/31/2023. It indicated Patient 6s symptoms were well managed with the hospice interventions, medications, and a plan of care, and she remained on a steady decline during her care with the agency. On 4/19/2023, at12 p.m., during a telephone interview with Physician 1 who had been a primary physician (PCP) of Patient 6 since 8/9/2017, the PCP stated she had not referred Patient 6 to the agency because Patient 6 did not have terminal illness and was not eligible to receive hospice service. PCP 1 stated nobody from the hospice agency had communicated with her regarding Patient 6s enrollment to the agency, and she did not know Patient 6 had enrolled with the hospice agency. Physician 1 stated she had not communicated with Physician 2 and she did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at12:15 p.m., he stated he was not able to find the documented evidence Patient 6 met the criteria for LCD eligibility, and the supporting documentation that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course (such as test result, and the consultation from Patient 6s primary care physician). A review of the agencys policy titled ";Admission Criteria and Process" revised in November 2020 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 intermediary Local Coverage Determinations (LCDs). The policy also indicated the agency will admit a patient only on recommendation of the medical director in consultation with or input from, the patients attending physician, if any. 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. On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on interview and record review, the hospice agency (HA) failed to provide evidence that the quality assessment and performance improvement (QAPI, a coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI), which are critical to improving the quality of life, and quality of care and services delivered in a healthcare facility) system was formulated and to ensure its program objectives, patient care disciplines, description of how the program will be administered and coordinated, methodology for monitoring and evaluating the quality of care, priorities for resolution of problems, monitoring to determine effectiveness of action, oversight responsibility reports to governing body, and documentation of the review of its own QAPI program were implemented. This deficient practice had the potential to result in the inability of the agency to identify issues, improve health outcomes, patient safety, and quality patient care, and had the potential to affect the care provided to the patients. --- During an interview with the Director of Patient Care Services (DPCS) on 4/20/23, at 4:10 p.m., he stated he was new and had became the DPCS on March 2023 and could not find/provide the evidence a functioning QAPI (QAPI, a coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI), which are critical to improving the quality of life, and quality of care and services delivered in a healthcare facility) program had been maintained. The DPCS stated he could not find/provide QAPI meeting minutes, or any documentation with signatures of core staff who had attended. The DPCS stated previous Medical Director, Administrator and the DPCS are no longer working for the agency. A review of the agencys policy and procedure titled ";Improving organizational performance" revised in November 2020 indicated performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. A review of the agencys job description summary for the Director of Patient Care Services indicated the DPCS is responsible for the implementation and monitoring of the organizations quality assessment performance improvement (QAPI) program. On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as evidence by: The hospice agency failed to: 1.Ensure patients clinical information were reviewed to ensure the initial certifications for the three of six sampled patients (Patients 1, 5, 6), were accurate. These deficient practices resulted in the agency certifying patients for hospice care, without documentation of clinical evidence to support its terminal illness and had the potential to result in an inappropriate care and services provided to the patients. (Refer to L667) 2.Ensure the medical director completed the ";Physicians Certification for Hospice Benefit" (CTI, illness with a prognosis of having 6 months of life or less) prior to its recertification for continued hospice care and services, for one of six sampled patients, (Patient 4). This deficient practice had the potential that patients who are no longer qualified to receive hospice care will continue with the services and can affect the quality of life for the affected patients. (Refer to L668) 3.Ensure accurate assessment and review of clinical record was conducted to verify patient clinical information necessary for initial certification and recertification of terminal illness for three of six sampled patients (Patients 4, 5, and 6). This deficient practice resulted in the hospice agency recertifying patients without verifying documentation of clinical evidence that support the terminal diagnoses. (Refer to L669) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services. --- . On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on interview and record review, the hospice agency failed to ensure patients clinical information were reviewed to ensure the initial certifications for the three of six sampled patients (Patients 1, 5, 6), were accurate. These deficient practices resulted in the agency certifying patients for hospice care, without documentation of clinical evidence to support its terminal illness and had the potential to result in an inappropriate care and services provided to the patients. --- a. On 4/18/23 at 12 p.m., during a clinical record review, Patient 1s clinical record indicated Patient 1 was admitted to the hospice agency (HA) on 3/22/23 with a primary diagnosis of AlzheimersDisease (progressive mental deterioration due to generalized degeneration of the brain). A review of the plan of care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 4/18/23 indicated the Skilled Nurse to visit Patient one time per week. The Medical Social Worker (MSW) to visit once a month, and the Spiritual Counsellor (SC) to visit once a month. A review of the agencys document titled, ";face to face encounter" dated 3/15/23 indicated Patient 1 weighed 199 pounds (lbs). A review of the agencys document titled, ";comprehensive nursing assessment", dated 3/22/23 indicated Patient 1 weighed 133lbs. On 4/20/2023 at 12:05 p.m., an interview was conducted in the agency conference room with the Director of Patient Care Services (DPCS), the DPCS stated the history and physical, dated 3/15/23, documented a weight of 199 lbs. for Patient 1 and was not the same with the initial assessment, dated 3/22/2023, that documented a weight of 133 lbs. DPCS stated this assessment of weight was not correct. b. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of hypertensive heart disease without heart failure. It was indicated in the face sheet that Physician 2 was the referring doctor. A review of the Comprehensive Nursing Assessment (as assessment conducted by a Registered Nurse and is based on a physical assessment of the individual and a review of the individual's medical records, including physician notes, lab results and all other pertinent clinical records) by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 5 was alert and oriented, was ambulatory using a cane and walker, needed moderate assistance in the activities of daily living except in feeding (needed minimal/supervision). Patient 5 could take approximately 40 steps before becoming exhausted and had mild dyspnea with moderate exertion. Patient was not on oxygen therapy, and her oxygen saturation was 96 percent in room air. Patient 5 did not have weight loss in the past 6 months, had adequate fluid intake, and her membrane was moist and had good turgor. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week, the Registered Nurse (RN) and the medical social worker (MSW)visit was once a month. The Spiritual counselor and the volunteer service was declined. There was no indication whether the hospice aide visit was declined or not. A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination, an assessment to determine patient's eligibility for hospice services) of "Heart Disease," dated 10/20/2022, indicated that the sections for "untreatable condition" and "New York Heart Association (NYHA, classification provides a simple way of classifying the extent of heart failure), classification" must be met to determine patient's eligibility for hospice services. The form indicated that Patient 5 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record for Patient 5 indicated there was no documentation supporting Patient 5 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level". The clinical record indicated there was no documented evidence Patient 5 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," (the document that showed a physician certified a patient's eligibility for hospice benefit) for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 5's terminal diagnosis was hypertensive heart disease without heart failure. It indicated Patient 5 was alert and oriented, ambulatory with walker or a cane, could take approximately 40 steps before becoming exhausted and becomes SOB with moderate exertion. Patient 5s oxygen saturation was 96 percent in room air. Patient 5 did not have weight loss in the past 6 months, had adequate fluid intake, and her membrane was moist and had good turgor. It indicated Patient 5 met the criteria for LCD eligibility and the Medical Director had certified that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of the Discharge Summary indicated Patient 5 was hospitalized on 3/31/2023, and Patient 5s care was ended on 3/31/2023. It indicated Patient 5s symptoms were well managed with the hospice interventions, medications, and a plan of care, and she was remained on a steady decline during her care with the agency. On 4/20/2023, at 10:50 a.m., the Surveyor called Patient 5s phone number on record, Patient 5s caregiver (CG)/Family member 2 (FM2) answered the phone call. During the telephone interview, Patient 5s CG/FM 2 stated Patient 5 could not communicate with the Surveyor because Patient 5 uses non dominant language. FM 2 stated she was not aware that the hospice service was for the person whose life expectancy was less than 6 months and did not know what the hospice meant. FM 2 stated Patient 5 should have not received the hospice service because Patient 5 was not dying nor had been told that Patient 5 had 6 months or less to live. FM 2 stated Physician 1 was Patient 6's primary doctor, and she did not know who Physician 2 was. On 4/19/2023, at 12 p.m., during a telephone interview with Physician 1, who had been the primary physician of Patient 5 since 7/9/2014,Physician 1 stated she had not referred Patient 5 to the agency because Patient 5 did not have a terminal illness and was not eligible to receive hospice service. Physician 1 stated nobody from the hospice agency had communicated with her regarding Patient 5s enrollment to the agency, and she did not know Patient 5 had enrolled in the hospice agency. Physician 1 stated She had not communicated with Physician 2 and she did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at 12:15 p.m., he stated he was not able to find the documented evidence Patient 5 met the criteria for LCD eligibility, and the supporting documentation that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course, such as test result, and the consultation from Patient 5s primary care physician. The DPCS stated Physician 2 was a "Mobile doctor." During a telephone interview with the current Medical Director (MD) on 4/20/2023, at 12:48 p.m., she stated she became the Medical Director of the hospice agency less than a month ago. The MD stated when the agency admits the patient to the hospice agency, the MD/NP should see the patient (physically or facetime), interview family and patient, communicate with the patients primary physician and review the history and physical from the patients primary physician, review the hospital record (if any), and review the RNs assessment and LCD assessment. c. A review of Patient 6's (Patient 6 was Patient 5s family member) electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery. The face sheet indicated that Physician 2 was the referring doctor. A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was hypertensive heart disease without heart failure. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 6 was alert and oriented, was ambulatory without using a cane and walker, needed minimal supervision for all activities of daily living (ADL) but needed moderate assistance in toileting. Patient 6 had shortness of breath (SOB) after moderate activity. Patient 6 was not on oxygen therapy, and his oxygen saturation was 98 percent on room air. Patient 6 did not have significant weight loss in the past six months. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor, the hospice aide service, and the volunteer service was declined. A review of the form titled, "LCD Hospice Eligibility Determination" of "Heart Disease," dated 10/20/2022, indicated the sections for "Untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine the patient's eligibility for hospice services. The form indicated Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation to support Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level." A review of the clinical record indicated there was no documented evidence Patient 6 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," for the first 90-day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was atherosclerotic heart disease of native coronary artery. It indicated Patient 6 was alert and oriented, ambulatory without need of walker or a cane, and became short of breath with moderate exertion. Patient 6s oxygen saturation (oxygen level in the blood, with normal range of 95-100%) was measured as 98 percent on room air. Patient 6 did not have significant weight loss in the past six months. It also indicated Patient 6 met the criteria for LCD eligibility, and the Medical Director had certified that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. On 4/20/2023, at 10:50 a.m., when the Surveyor called Patient 6s number of record, Patient 6s caregiver (CG)/Family member 2 (FM2) answered the phone call. During a telephone interview with Patient 6s CG/FM 2, she stated Patient 6 could not communicate with the Surveyor because Patient 5 uses non dominant language. FM 2 stated she was not aware the hospice service was for the person whose life expectancy was less than six months, and did not know what the hospice meant. FM 2 stated she was told the hospice service was provided at home instead of the patient going to other place to receive care. FM 2 stated Patient 6 should have not received the hospice service because Patient 6 was not dying nor had been told that Patient 6 had 6 months or less to live. FM 2 stated Physician 1 was Patient 6's primary doctor, and she did not know who Physician 2 was. A review of the Discharge Summary indicated Patient 6 was hospitalized on 3/31/2023, and Patient 6s care was ended on 3/31/2023. It indicated Patient 6s symptoms were well managed with the hospice interventions, medications, and a plan of care, and she was remained on a steady decline during his care with the agency. On 4/19/2023, at12 p.m., during a telephone interview with Physician 1 who had been a primary physician (PCP) of Patient 6 since 8/9/2017, Physician 1 stated she had not referred Patient 6 to the agency because Patient 6 did not have a terminal illness and was not eligible to receive hospice service. PCP 1 stated nobody from the hospice agency had communicated with her regarding Patient 6s enrollment to the agency, and she did not know Patient 6 had enrolled with the hospice agency. Physician 1 stated she had not communicated with Physician 2 and she did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at12:15 p.m., he stated he was not able to find the documented evidence Patient 6 met the criteria for LCD eligibility, and the supporting documentation that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course (such as test result, and the consultation from Patient 6s primary care physician). The DPCS stated Physician 2 was a "Mobile doctor." There was a ";Termination Agreement" signed by the previous Medical Director which indicated the previous Medical Director would terminate the ";Professional Services Agreement, Medical Director" as of March 5, 2023. During a telephone interview with the current Medical Director (MD) on 4/20/2023, at 12:48 p.m., she stated she became a Medical Director of the hospice agency less than a month ago. The MD stated when the agency admits a patient to the hospice agency, the MD/NP should see the patient (physically or via facetime), interview family and patient, communicate with the patients primary physician and review the history and physical from the patients primary physician, review the hospital record (if any), review the RNs assessment and LCD assessment. A review of the agencys policy titled ";Admission Criteria and Process", revised November 2020 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). The policy also indicated the agency will admit a patient only on recommendation of the medical director in consultation with or input from, the patients attending physician, if any. 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. A review of the agencys policy and procedure titled ";Certification of Terminal Illness" revised in November 2020 indicated as follows: At the time of admission to hospice, the hospice Medical Director or the patients attending physician will complete a certification narrative that reflects the patients individual circumstances based on: his/her review of the patients medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms). On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on observation, interview and record review, the hospice agency failed to ensure the medical director completed the ";Physicians Certification for Hospice Benefit" (CTI, illness with a prognosis of having 6 months of life or less) prior to its recertification for continued hospice care and services, for one of six sampled patients, (Patient 4). This deficient practice had the potential that patients who are no longer qualified to receive hospice care will continue with the services and can affect the quality of life for the affected patients. --- A review of Patient 4's clinical record indicated a start of care (SOC) date of 12/12/2022, with a primary diagnosis atherosclerotic heart disease of native coronary artery (heart disease). A review of the Comprehensive Nursing Assessment (in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) dated 12/12/2022 indicated Patient 4 was alert and oriented, ambulatory with a cane and a walker, and needed moderate to maximal assistance for the activities of daily living (ADL). Patient 4 had moderate dyspnea at rest and oxygen saturation (the amount of oxygen in the bloodstream with normal range of 95-100%) rate was 94 percent with two (2) liters of oxygen administration. A review of Patient 4's Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 12/12/2022, indicated the Registered Nurse (RN) frequency of visits every 14 days or sooner. The Licensed Vocational Nurse visits were once per week and the Medical Social Worker (MSW) and Spiritual Counsellor (SC) visits were on initial evaluation then once a month. On 4/19/2023, at 10 a.m., during a joint home visit to Patient 4s residence with the Director of Patient Care Services (DPCS), Patient 4 was alert and oriented, and able to communicate well. Patient 4 was receiving oxygen at 3.5 liters per minute via nasal cannula. A review of the ";Physicians Certification for Hospice Benefit" (CTI, illness with a prognosis of having 6 months of life or less) from 3/12/2023 to 5/10/2023 indicated the space for the physicians narrative was left blank. The previous Medical Directors name was typed on the form, but the space for the signature and date was left blank. During an interview with the Director of Patient Care Services (DPCS) on 4/20/2023, at 2:40 p.m., the DPCS stated Patient 4s ";Physicians Certification for Hospice Benefit" from 3/12/2023 to 5/10/2023 was not conducted yet. The DPCS also stated the ";Physicians Certification for Hospice Benefit (CTI)" should have been completed before the recertification of hospice benefit started. The ";Termination Agreement" signed by the previous Medical Director indicated the previous Medical Director would terminate the ";Professional Services Agreement, Medical Director" as of March 5, 2023. During a telephone interview with the current Medical Director (MD) on 4/20/2023, at 12:48 p.m., the MD stated she became a Medical Director of the hospice agency less than a month ago. The current MD stated when the agency recertifies the hospice service, the MD/NP should sign, ";see the patient (physically or facetime), interview family and patient, review medical documentation including the Registered Nurses (RN) assessment, SN notes, LCD assessment, and the Medical Director should sign the ";Physicians Certification for Hospice Benefit (CTI)" before the benefit begins A review of the agencys policy and procedure titled ";Certification of Terminal Illness", revised in November 2020, indicated 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. On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on observation, interview and record review, the hospice agency failed to ensure accurate assessment and review of clinical record was conducted to verify patient clinical information necessary for initial certification and recertification of terminal illness for three of six sampled patients (Patients 4, 5, and 6). This deficient practice resulted in the hospice agency recertifying patients without verifying documentation of clinical evidence that support the terminal diagnoses. --- a. A review of Patient 4's clinical record indicated a start of care (SOC) date of 12/12/2022, with a primary diagnosis atherosclerotic heart disease of native coronary artery (heart disease). A review of the Comprehensive Nursing Assessment (in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) dated 12/12/2022, indicated Patient 4 was alert and oriented, ambulatory with a cane and a walker, and needed moderate to maximal assistance for the activities of daily living (ADL). Patient 4 had moderate dyspnea at rest and oxygen saturation rate (the amount of oxygen in the bloodstream with normal range of 95-100%) was measured as 94 percent at two liters of oxygen administration. A review of Patient 4's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) /Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 12/12/2022, indicated the Registered Nurse (RN) frequency of visits for every 14 days or sooner. The Licensed Vocational Nurse (LVN) visits were once per week and the Medical Social Worker (MSW) and Spiritual Counsellor (SC) visits were on initial evaluation and then once a month. On 4/19/2023, at 10 a.m., during a joint home visit to Patient 4s residence with the Director of Patient Care Services (DPCS), Patient 4 was alert and oriented, and able to communicate well. Patient 4 was receiving oxygen at 3.5 liters per minute via nasal cannula. A review of the ";Physicians Certification for Hospice Benefit (CTI)" from 3/12/2023 to 5/10/2023 indicated the space for the physicians narrative was left blank. There was previous Medical Directors name was typed in the form, but the space for the signature and date was left blank. During an interview with the Director of Patient Care Services (DPCS) on 4/20/2023, at 2:40 p.m., he stated Patient 4s ";Physicians Certification for Hospice Benefit (CTI)" from 3/12/2023 to 5/10/2023 was not conducted yet. He stated the ";Physicians Certification for Hospice Benefit" (CTI, illness with a prognosis of having 6 months of life or less) should have been completed before the recertification of hospice benefit started. During a telephone interview with the Current Medical Director (MD) on 4/20/2023, at 12:48 p.m., she stated she became a Medical Director of the hospice agency less than a month ago. The current MD stated when the agency recertified the hospice benefit, the MD/NP (Nurse Practitioner) should see the patient physically or via facetime, interview family and patient, review the medical record including the RN assessment, SN Note, and the Medical Director should sign the CTI before the benefit begins. b. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of hypertensive heart disease without heart failure. It indicated that Physician 2 was the referring doctor. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 5 was alert and oriented, was ambulatory using a cane and walker, needed moderate assistance in the activities of daily living except in feeding (needed minimal/supervision). Patient 5 could take approximately 40 steps before becoming exhausted and had mild dyspnea with moderate exertion. Patient 5 was not on oxygen therapy, and her oxygen saturation was measured as 96 percent on room air. Patient 5 did not have weight loss in the past six months, had adequate fluid intake, and her membrane was moist and had fairly good skin turgor. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor and the volunteer service was declined. There was no indication whether the hospice aide visit was declined or not. A review of the form titled, "LCD Hospice Eligibility Determination" (LCD, Local Coverage Determination, an assessment to determine a patient's eligibility for hospice services) of "Heart Disease," dated 10/20/2022, indicated the sections for an "Untreatable condition" and "New York Heart Association (NYHA, classification that provides a simple way of classifying the extent of heart failure) classification" must be met to determine a patient's eligibility for hospice services. The form indicated Patient 5 met the criteria for "Untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation supporting Patient 5 met the criteria for an "untreatable condition" and "NYHA classification" for "NYHA Class IV level." A review of the clinical record indicated there was no documented evidence Patient 5 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 5's terminal diagnosis was hypertensive heart disease without heart failure. It indicated Patient 5 was alert and oriented, ambulatory with walker or a cane, could take approximately 40 steps before becoming exhausted and becomes SOB with moderate exertion. Patient 5s oxygen saturation was measured as 96 percent on room air. Patient 5 did not have weight loss in the past six months, had adequate fluid intake, and her membranes were moist, and she had fairly good skin turgor. It indicated Patient 5 met the criteria for LCD eligibility, and the Medical Director had certified that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. The previous Medical Directors electronic signature was on the CTI. A review of the Discharge Summary indicated Patient 5 was hospitalized on 3/31/2023, and Patient 5s care ended on 3/31/2023. It indicated Patient 5s symptoms were well managed with the hospice interventions, medications and a plan of care, and she remained on a steady decline during her care with the agency. On 4/20/2023, at 10:50 a.m., when the Surveyor called Patient 5s number of record, Patient 5s caregiver (CG)/Family member 2 (FM2) answered the phone call. During a telephone interview with Patient 5s CG/FM 2, she stated Patient 5 could not communicate with the Surveyor because Patient 5 uses non dominant language. FM 2 stated she was not aware that the hospice service was for the person whose life expectancy was less than six months and did not know what hospice meant. FM 2 stated Patient 5 should have not received the hospice service because Patient 5 was not dying nor had been told that Patient 5 had six months or less to live. On 4/19/2023, at 12 p.m., during a telephone interview with Physician 1 who had been the primary physician of Patient 5 since 7/9/2014, stated she had not referred Patient 5 to the agency because Patient 5 did not have terminal illness and was not eligible to receive hospice service. Physician 1 stated nobody from the hospice agency had communicated with her regarding Patient 5s enrollment to the agency and did not know Patient 5 had enrolled in the hospice agency. Physician 1 stated she had not communicated with Physician 2 and she did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at 12:15 p.m., the DPCS stated he was not able to find the documented evidence Patient 5 met the criteria for LCD eligibility, and the supporting documentation that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course, such as test result, and the consultation from Patient 5s primary care physician. The DPCS stated Physician 2 was a "Mobile doctor". The ";Termination Agreement" signed by the previous Medical Director which indicated the previous Medical Director would terminate the ";Professional Services Agreement, Medical Director" as of March 5, 2023. During a telephone interview with the Current Medical Director (MD) on 4/20/2023, at 12:48 p.m., she stated she became a Medical Director of the hospice agency less than a month ago. The MD stated when the agency admits the patient to the hospice agency, the MD/NP should see the patient physically or via facetime, interview family and patient, communicate with the patients primary physician and review the history and physical from the patients primary physician, review the hospital record (if any), and review the RNs assessment and LCD assessment. c. A review of Patient 6's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery. A review of the "Physician's Certification for Hospice Benefit," for the first 90-day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was hypertensive heart disease without heart failure. It was indicated that Physician 2 was the referring doctor. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 6 was alert and oriented, was ambulatory without using a cane and walker, needed minimal supervision for all activities of daily living (ADL) but needed moderate assistance in toileting. Patient 6 became to have shortness of breath (SOB) after moderate activity. Patient 6 was not on oxygen therapy, and his oxygen saturation was measured as 98 percent on room air. Patient 6 did not have significant weight loss in the past six months. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor, the hospice aide service, and the volunteer service was declined. A review of the form titled, "LCD Hospice Eligibility Determination" of "Heart Disease," dated 10/20/2022, indicated the sections for "Untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation supporting Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level". A review of the clinical record indicated there was no documented evidence Patient 6 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," for the first 90-day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was atherosclerotic heart disease of native coronary artery. It indicated Patient 6 was alert and oriented, ambulatory without need walker or a cane, becomes SOB with moderate exertion. Patient 6s oxygen saturation was 98 percent in room air. Patient 6 did not have significant weight loss in the past 6 months. It indicated Patient 6 met the criteria for LCD eligibility, and the Medical Director had certified that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. There was only the previous Medical Directors electronic signature on the CTI. On 4/20/2023, at 10:50 a.m., when the Surveyor called Patient 6s number on the record, Patient 6s caregiver (CG)/Family member 2 (FM2) answered the phone call. During a telephone interview with Patient 6s CG/FM 2, she stated Patient 6 could not communicate with the Surveyor because Patient 6 uses non dominant language. FM 2 stated she was not aware the hospice service was for the person whose life expectancy was less than six months, and did not know what hospice meant. FM 2 stated Patient 6 should have not received the hospice service because Patient 6 was not dying nor had been told that Patient 6 had six months or less to live. A review of the Discharge Summary indicated Patient 6 was hospitalized on 3/31/2023, and Patient 6s care was ended on 3/31/2023. It indicated Patient 6s symptoms were well managed with the hospice interventions, medications and a plan of care, and she remained on a steady decline during her care with the agency. On 4/19/2023, at12 p.m., during a telephone interview with Physician 1 who had been a primary physician (PCP) of Patient 6 since 8/9/2017, Physician 1 stated she had not referred Patient 6 to the agency because Patient 6 did not have a terminal illness and was not eligible to receive hospice service. Physician 1 stated nobody from the hospice agency had communicated with her regarding Patient 6s enrollment to the agency, and she did not know Patient 6 had enrolled with the hospice agency. Physician 1 stated she had not communicated with Physician 2 and she did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at 12:15 p.m., he stated he was not able to find the documented evidence Patient 6 met the criteria for LCD eligibility, and the supporting documentation that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course (such as test result, and the consultation from Patient 6s primary care physician). The DPCS stated Physician 2 was a "Mobile doctor". The ";Termination Agreement" signed by the previous Medical Director which indicated the previous Medical Director would terminate the ";Professional Services Agreement, Medical Director" as of March 5, 2023. During a telephone interview with the current Medical Director (MD) on 4/20/2023, at 12:48 p.m., she stated she became a Medical Director of the hospice agency less than a month ago. The MD stated when the agency admits the patient to the hospice agency, the MD/NP should see the patient (physically or via facetime), interview family and patient, communicate with the patients primary physician and review the history and physical from the patients primary physician, review the hospital record (if any), and review the RNs assessment and LCD assessment. The current MD stated the Medical Director should ensure the hospice patients' eligibility and oversee the agency's operation. A review of the agencys policy titled ";Admission Criteria and Process" revised in November 2020 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 intermediary Local Coverage Determinations (LCDs). A review of the agencys policy and procedure titled ";Certification of Terminal Illness" revised in November 2020 indicated as follows: At the time of admission to hospice, the hospice Medical Director or the patients attending physician will complete a certification narrative that reflects the patients individual circumstances based on his/her review of the patients medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms). A review of the agencys policy titled ";Professional Services Agreement for Medical Director" revised in November 2020 indicated the duties and responsibilities of the Medical Director will include, but not be limited to providing overall medical direction to the program including supervision of all hospice physician employees and contract hospice physician, and reviewing the patients medical eligibility for hospice services and providing written certification of the terminal illness for all subsequent benefit periods. On 5-31-23 at 10:50am owner and office manager arrived at agency and stated 911 Hospice is currently nonoperational with no patients and no staff since May 1, 2023. Office manager further stated, the Plan of Correction was not done because agency could not pay staff to complete it due to financial hardship.

Based on interview and record review, the Hospice Agency (HHA) failed to ensure the emergency preparedness training for all staffs was conducted at least annually. This failure had the potential to result in the hospice staffs lack of knowledge to readily and effectively respond during an emergency crisis situation. --- During a review of the agency's emergency preparedness program documentation, the agency had no documented evidence the emergency preparedness training was conducted for all staff. On 4-20-23, at 12:05 p.m., during an interview with the DPCS, he stated the agency's emergency preparedness plan is not complete and needs work. During a review of the agency's policy entitled "Emergency Management Plan" with a revised date of November 2020, it indicated the agency will comply with all applicable, Federal, State, and local emergency preparedness program that meets those regulations.

Based on observation, interview, and record review, the hospice agency failed to ensure that the Condition of Participation regarding Patients' rights was met as follows: The hospice agency, for the three (3) of six (6) sampled patients, Patient 1, Patient 5, and Patient 6, failed to ensure the information regarding patients rights were provided to the patients and caregivers in a manner that they could understand, , This deficient practice had the potential to cause miscommunication and misunderstanding, which can affect the quality of care and services provided to all the patients under the agencys care. (Refer to L 502) The cumulative effect of these systemic practices resulted in the hospice agency's failure to protect the rights for admitted patients. --- .

Based on interview and record review, for three (3) of six (6) sampled patients, Patient 1, Patient 5, and Patient 6, the hospice agency failed to ensure the information regarding patients rights were provided to the patients and caregivers in a manner that they could understand. This deficient practice had the potential to cause miscommunication and misunderstanding, which can affect the quality of care and services provided to all the patients under the agencys care. --- b. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of hypertensive heart disease without heart failure. A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 1's terminal diagnosis was hypertensive heart disease without heart failure. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 5 was alert and oriented, was ambulatory using a cane and walker, needed moderate assistance in activities of daily living except in feeding (needed minimal/supervision). Patient 5 could take approximately 40 steps before becoming exhausted and had mild dyspnea with moderate exertion. Patient 5 was not on oxygen therapy, and her oxygen saturation was 96 percent on room air. Patient 5 did not have weight loss in the past six months, had adequate fluid intake, and her membranes were moist, and Patient 5 had good skin turgor. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor and the volunteer service was declined. There was no indication whether the hospice aide visit was declined or not. A review of the Discharge Summary indicated Patient 5 was hospitalized on 3/31/2023, and Patient 5s care was ended on 3/31/2023. It indicated Patient 5s symptoms were well managed with the hospice interventions, medications, and a plan of care, and she remained on a steady decline during her care with the agency. On 4/20/2023, at 10:50 a.m., when the Surveyor called Patient 5s number of record, Patient 5s caregiver (CG)/Family member 2 (FM2) answered the phone. During a telephone interview with Patient 5s CG/FM 2, she stated Patient 5 could not communicate with the Surveyor because Patient 5 uses a non-dominant language. FM 2 stated she was with Patient 5 when the nurse from the agency (who did not speak the language Patient 5 uses) came to the patients house on the admission date and translated to Patient 5 what the nurse said. FM 2 stated she was not aware that the hospice service was for the person whose life expectancy was less than six months and did not know what hospice meant. FM 2 stated the nurse from the agency did not explain about the hospice service and Patient 5 should have not received the hospice service because Patient 5 was not dying nor had been told that Patient 5 had six months or less to live. When FM 2 was asked whether she was informed about Patient 5 facing possible limitations of existing medical service when enrolling in hospice, FM2 stated she was not informed. When asked whether the agency had provided Patient 5 the written notice of ";Patient Rights" and responsibilities in a language that Patient 5 could understand, she stated ";No." A review of the ";Hospice Admission Services Agreement" dated 10/20/2023 (was written in the dominant language, not written in the language Patient 5 uses), indicated Patient 5s signature. However, there was no documented evidence in the clinical record that Patient 5 was provided ";Hospice Admission Services Agreement" written in the language that Patient 5 could understand. A review of the ";Patient/Family Bill of Right" dated 10/20/2022 indicated Patient 5 signature. However, there was no documented evidence ";Patient/Family Bill of Right" was provided written in the language that Patient 5 could understand. c. A review of Patient 6's (Patient 6 was Patient 5s family member) electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of Atherosclerotic heart disease of native coronary artery. A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was hypertensive heart disease without heart failure. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 6 was alert and oriented, was ambulatory without using a cane and walker, needed minimal supervision for all activities of daily living (ADL) but needed moderate assistance in toileting. Patient 6 has shortness of breath (SOB) after moderate activity. Patient 6 was not on oxygen therapy, and his oxygen saturation was 98 percent on room air. Patient 5 did not have significant weight loss in the past six months. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor, the hospice aide service, and the volunteer service was declined. A review of the Discharge Summary indicated Patient 6 was hospitalized on 3/31/2023, and Patient 6s care was ended on 3/31/2023. It indicated Patient 6s symptoms were well managed with the hospice interventions, medications, and a plan of care, and remained on a steady decline during his care with the agency. On 4/20/2023, at 10:50 a.m., when the Surveyor called Patient 6s number of record, Patient 6s CG/FM2 (Same as Patient 5s CG/FM) answered the phone call. During a telephone interview with Patient 6s CG/FM 2, she stated Patient 6 could not communicate with the Surveyor because Patient 6 uses a non-dominant language. FM 2 stated she was with Patient 6 when the nurse from the agency (who did not speak the language Patient 6 uses) came to the patients house on the admission date and translated to Patient 6 what the nurse had said. FM 2 stated she was not aware that the hospice service was for a person whose life expectancy was less than six months and did not know what hospice meant. FM 2 stated the nurse from the agency did not explain about the hospice service and Patient 6 should have not received the hospice service because Patient 6 was not dying nor had been told that Patient 6 had six months or less to live. When FM 2 was asked whether she was informed about Patient 6 facing possible limitations of existing medical service when enrolling in hospice, FM2 stated she was not informed. When asked whether the agency had provided Patient 6 the written notice for ";Patient Rights and Responsibilities" in a language that Patient 6 could understand, she stated ";No." A review of the ";Hospice Admission Services Agreement" dated 10/20/2023 (was written in the dominant language, not written in the language Patient 6 uses), indicated Patient 6s signature. However, there was no documented evidence in the clinical record that Patient 6 was provided ";Hospice Admission Services Agreement" written in the language that Patient 6 could understand. A review of the ";Patient/Family Bill of Right" (written in dominant language) dated 10/20/2022 indicated Patient 6signature. However, there was no documented evidence written ";Patient/Family Bill of Right" was provided in the language that Patient 6 could understand. On 4/20/23, at 12:10 p.m., during an interview with the Director of Patient Care Services (DPCS) after he spoke with RN 1(who admitted Patient 5 and Patient 6) over the phone, the DPCS stated RN 1 told him that RN 1 could not speak the language that Patient 5 and Patient 6 uses. RN 1 told the DPCS that he had not provided ";Hospice Admission Services Agreement" and ";Patient/Family Bill of Right" written in the language that Patient 5 and Patient 6 could understand. The DPCS was unable to provide documented evidence the agency had provided ";Hospice Admission Services Agreement" and ";Patient/Family Bill of Right" written in a language that Patient 5 and Patient 6 could understand. A review of the agencys policy and procedure titled ";Patient Bill of Right/Responsibilities" revised in November 2020 indicated as follows: · Upon admission, the admitting clinician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights/Responsibilities in advance of furnishing care. · The Patient Bill of Right/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 review of the agencys policy and procedure titled ";Informed Consent/Refusal of Treatment" revised in November 2020 indicated upon admission and throughout the course of care/service, the patient and family/caregiver will be given information in an understandable language to make decisions regarding the care and services being provided. a. On 4/18/23, a review of Patient 1s clinical record indicated Patient 1 was admitted to the hospice agency (HA) on 3/22/23 with a primary diagnosis of Alzheimers Disease (progressive mental deterioration due to generalized degeneration of the brain). A review of the POC dated 4/18/23 indicated the Skilled Nurse was to visits Patient 1, one time per week. The Medical Social Worker (MSW) was to visit once per month and the Spiritual Counselor (SC) was to visit once per month. A review of Patient 1s patient rights consent signed on 3/22/23, the day of initial assessment indicated it was presented to the patient and caregiver in English when their primary language was Arabic. On 4/20/23 at 12:05pm an interview was conducted in the agency conference room with DPCS, he stated the agency does not have any documentation in the patient/caregivers native language. The DPCS stated an interpreter was used for home visits and all communication with the patient/caregiver, but the DPCS could not produce any documented proof.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of Patients was met as followed: The hospice agency failed to determine the patient's eligibility for hospice care and services and failed to identify the terminal illness that met the criteria for hospice care and services, for the three of six sampled patients (Patient 1, Patient 5 and Patient 6). This deficient practice resulted in patients ineligible for hospice care were enrolled under hospice care, which can affect the quality of life, and in maintaining their highest practicable physical, mental and psychosocial wellbeing. (Refer to L 524). The cumulative effects 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 benefits. --- .

Based on observation, interview and record review, the hospice agency failed to determine the patient's eligibility for hospice care and services and failed to identify the terminal illness that met the criteria for hospice care and services, for the three of six sampled patients (Patient 1, Patient 5 and Patient 6). This deficient practice resulted in patients ineligible for hospice care were enrolled under hospice care, which can affect the quality of life, and in maintaining their highest practicable physical, mental and psychosocial wellbeing. --- a. On 4/18/23, a review of Patient 1s clinical record indicated Patient 1 was admitted to the hospice agency (HA) on 3/22/23 with a primary diagnosis of Alzheimers Disease (progressive mental deterioration due to generalized degeneration of the brain). A review of the POC dated 4/18/23 indicated the Skilled Nurse to visit Patient one time per week. The MSW to visit once a month, and the SC to visit once a month. A review of the agencys document entitled face to face encounter dated 3/15/23 indicated Patient 1 weighed 199 lbs. A review of the agencys document entitled comprehensive nursing assessment dated 3/22/23 indicated Patient 1 weighed 133lbs. On 4/20/23 at 12:05 p.m., an interview was conducted in the agency conference room with DPCS, he stated the history and physical, dated 3/15/23, documented a weight of 199 lbs for Patient 1 and is not congruent (the same) with the initial assessment, dated 3/22/23, which documented a weight of 133 lbs for Patient 1. DPCS stated this assessment of weight was not correct. b. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of hypertensive heart disease without heart failure. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 5 was alert and oriented, was ambulatory using a cane and walker, needed moderate assistance in the activities of daily living except in feeding (needed minimal/supervision). Patient 5 could take approximately 40 steps before becoming exhausted and had mild dyspnea with moderate exertion. Patient was not on oxygen therapy, and her oxygen saturation was 96 percent in room air. Patient 5 did not have weight loss in the past 6 months, had adequate fluid intake, and her membrane was moist and had fairly good turgor. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week, the Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor and the volunteer service was declined. There was no indication whether the hospice aide visit was declined or not. A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Heart Disease," dated 10/20/2022, indicated that the sections for "untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated that Patient 5 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation supporting Patient 5 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level". A review of the clinical record indicated there was no documented evidence Patient 5 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," (the document that showed a physician certified a patient's eligibility for hospice benefit) for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 5's terminal diagnosis was hypertensive heart disease without heart failure. It indicated Patient 5 was alert and oriented, ambulatory with walker or a cane, could take approximately 40 steps before becoming exhausted and becomes SOB with moderate exertion. Patient 5s oxygen saturation was 96 percent in room air. Patient 5 did not have weight loss in the past 6 months, had adequate fluid intake, and her membrane was moist and had fairly good turgor. It indicated Patient 5 met the criteria for LCD eligibility. It indicated the Medical Director had certified that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of the Discharge Summary indicated Patient 5 was hospitalized on 3/31/2023, and Patient 5s care was ended on 3/31/2023. It indicated Patient 5s symptoms were well managed with the hospice interventions, medications and a plan of care, and she was remained on a steady decline during her care with the agency. On 4/20/2023, at 10:50 a.m., when the Surveyor called Patient 5s number on the record, Patient 5s caregiver (CG)/Family member 2 (FM2) answered the phone call. During a telephone interview with Patient 5s CG/FM 2, she stated Patient 5 could not communicate with the Surveyor because Patient 5 uses non dominant language. FM 2 stated she was not aware that the hospice service was for the person whose life expectancy was less than 6 months, and did not know what the hospice meant. FM 2 stated Patient 5 should have not received the hospice service because Patient 5 was not dying nor had been told that Patient 5 had 6 months or less to live. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at12:15 p.m., he stated he was not able to find the documented evidence Patient 5 met the criteria for LCD eligibility, and the supporting documentation that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course, such as test result, and the consultation from Patient 5s primary care physician. c. A review of Patient 6's (Patient 6 was Patient 5s family member) electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of Atherosclerotic heart disease of native coronary artery. A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was hypertensive heart disease without heart failure. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 6 was alert and oriented, was ambulatory without using a cane and walker, needed minimal supervision for all activities of daily living (ADL) but needed moderate assistance in toileting. Patient became to have shortness of breath (SOB) after moderate activity. Patient was not on oxygen therapy, and his oxygen saturation was 98 percent in room air. Patient 6 did not have significant weight loss in the past 6 months. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week, the Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor, the hospice aide service, and the volunteer service was declined. A review of the form titled, "LCD Hospice Eligibility Determination" of "Heart Disease," dated 10/20/2022, indicated that the sections for "untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated that Patient 6 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation supporting Patient 6 met the criteria for "untreatable condition" and "NYHA classification" for "NYHA Class IV level". A review of the clinical record indicated there was no documented evidence Patient 6 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," (the document that showed a physician certified a patient's eligibility for hospice benefit) for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 5's terminal diagnosis was hypertensive heart disease without heart failure. It indicated Patient 6 was alert and oriented, ambulatory without need walker or a cane, becomes SOB with moderate exertion. Patient 6s oxygen saturation was 98 percent in room air. Patient 6 did not have significant weight loss in the past 6 months. It indicated Patient 6 met the criteria for LCD eligibility. It indicated the Medical Director had certified that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. On 4/20/2023, at 10:50 a.m., when the Surveyor called Patient 6s number on the record, Patient 6s caregiver (CG)/Family member 2 (FM2) answered the phone call. During a telephone interview with Patient 6s CG/FM 2, she stated Patient 6 could not communicate with the Surveyor because Patient 5 uses non dominant language. FM 2 stated she was not aware that the hospice service was for the person whose life expectancy was less than 6 months, and did not know what the hospice meant. FM 2 stated Patient 6 should have not received the hospice service because Patient 6 was not dying nor had been told that Patient 6 had 6 months or less to live. A review of the Discharge Summary indicated Patient 6 was hospitalized on 3/31/2023, and Patient 6s care was ended on 3/31/2023. It indicated Patient 6s symptoms were well managed with the hospice interventions, medications and a plan of care, and she was remained on a steady decline during his care with the agency. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at12:15 p.m., he stated he was not able to find the documented evidence Patient 6 met the criteria for LCD eligibility, and the supporting documentation that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course (such as test result, and the consultation from Patient 6s primary care physician). A review of the agencys policy titled ";Admission Criteria and Process" revised in November 2020 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 intermediary Local Coverage Determinations (LCDs). The policy indicated during the initial assessment visit, the admitting clinician will assess the patients eligibility for hospice services according to the admission criteria and standard prognosis criteria to determine/confirm further. IT also indicated the hospice registered nurse will contact the physician for clinical information in writing to certify for hospice care.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met by failing to: 1. Ensure that the interdisciplinary group [IDG, team members from different disciplines,(physician, a registered nurse (RN), a social worker (SW), and a pastor or spiritual counselor), who are working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were attended by the team to discuss the patient's plan of care and progress for six of six sampled patients, (Patients 1, 2, 3, 4, 5, 6). This deficient practice had the potential that patients care needs are not assessed and addressed timely that can affect the quality of care necessary to maintain the highest practicable physical, mental, and psychosocial well-being of the patients under the agencys care. (Refer to L541). 2. Ensure the plan of care was followed and revised regarding the use of oxygen, to relieve the difficulty in breathing for one of six sampled patients, (Patient 4). This deficient practice can result in the agency not providing appropriate patient care and services necessary to maintain the patient's highest practicable well-being. (Refer to L 553). 3. Ensure oxygen supply was coordinated with the hospice agency personnel and failed to ensure the oxygen was available and accessible at home in case of respiratory distress, for one of six sampled patients, Patient 1. This deficient practice placed Patient 1 at risk for respiratory distress and discomfort when a respiratory crisis occurs. (Refer to L555). 4. Ensure abnormal vital signs (blood pressure, heart rate, respiratory rate, temperature), for one of six sampled patients (Patient 2) were reported to the physician as per (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers). This deficient practice had the potential to result in complications and delayed interventions when abnormal vital signs are not reported to the physician timely. (Refer to L 557). 5. 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), including the Medical Director, communicated with the patient's' primary care physician to verify the patient's hospice care eligibility, for two of six sampled patients (Patient 5, 6). This deficient practice resulted in certifying patients for hospice (terminally ill patients with 6 months or less to live) services without clinical evidence and documentation to support the diagnoses and provided hospice care and services to patients who were not hospice qualified. (Refer to L 558). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care is provided to the patients accurately assessed to receive hospice care and services. --- .

Based on interview and record review, the hospice agency failed to ensure that the interdisciplinary group [IDG, team members from different disciplines,(physician, a registered nurse (RN), a social worker (SW), and a pastor or spiritual counselor), who are working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were attended by the team to discuss the patient's plan of care and progress for six of six sampled patients, (Patients 1, 2, 3, 4, 5, 6). This deficient practice had the potential that patients care needs are not assessed and addressed timely that can affect the quality of care necessary to maintain the highest practicable physical, mental and psychosocial well-being of the patients under the agencys care. --- d. A review of Patient 4's clinical record indicated a start of care (SOC) date of 12/12/2022, with a primary diagnosis of atherosclerotic heart disease of native coronary artery. A review of Patient 4's Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 12/12/2022, indicated the Registered Nurse (RN) frequency of visits to PAtient 4 is every 14 days or sooner. The Licensed Vocational Nurse visits were to take place once per week. The Medical Social Worker (MSW) and Spiritual Counsellor (SC) visits were to be done for an initial evaluation then once a month. A review of Patient 4's "POC/IDG Review" indicated the spaces for signatures of the medical Director (MD), RN, and the MSW were left blank on 12/26/2022, 1/9/2023, 1/23/2023, 2/6/2023, 2/20/2023 and 3/6/2023. A review of Patient 4's "POC/IDG Review" indicated the spaces for signatures of the medical Director and the MSW were left blank on 12/12/2022 and 3/20/2023. A review of Patient 4's "POC/IDG Review" indicated the spaces for signatures of the medical Director, RN, SC, and the MSW were left blank on 4/3/2023. e. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of hypertensive heart disease without heart failure. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor and the volunteer service was declined. There was no indication whether the hospice visit was declined or not. A review of the "POC/IDG Review," indicated the spaces for signatures of the MD and the MSW were left blank on 10/20/2022, 10/31/2022, and 3/31/2023. A review of the "POC/IDG Review," indicated the spaces for signatures of the MD, RN, and the MSW were left blank on 11/14/2022, 11/28/2022, 12/12/2022, 12/26/2022, 1/9/2023, 1/23/2023, 2/6/2023, 2/20/2023, 3/6/2023 and 3/20/2023. f. A review of Patient 6's (Patient 6 was Patient 5s family member) electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery. A review of the "POC/IDG Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor, the hospice aide service, and the volunteer service was declined. A review of the "POC/IDG Review," indicated the spaces for signatures of the MD and the MSW were left blank on 10/20/2022 and 3/20/2023. A review of the "POC/IDG Review," indicated the spaces for signatures of the MD, RN, and the MSW were left blank on 10/31/2022, 11/14/2022, 11/28/2022, 12/12/2022, 12/26/2022, 1/9/2023, 1/23/2023, 2/6/2023, 2/20/2023 and 3/6/2023. During an interview with the Director of Patient Care Services (DPCS), on 4/20/2023, at 12:25 p.m., he was not able to provide the documented evidence the above disciplines had participated in the IDG meeting on above days. The DPCS stated the IDG team meeting should be held with participation of all the IDG members (MD, RN, MSW and SC) even though the patient had refused any of above service. A review of the agency's policy titled "Interdisciplinary Group Membership and Responsibilities" revised in November 2020 indicated the Interdisciplinary group responsibilities include participation in the establishment of the plan of care for each patient admitted to the hospice service and participation in the periodic review and updating of the plan of care for each patient receiving hospice services. a. On 4/18/23, a review of Patient 1s clinical record indicated Patient 1 was admitted to the hospice agency (HA) on 3/22/23 with a primary diagnosis of Alzheimers Disease (progressive mental deterioration due to generalized degeneration of the brain). A review of the POC dated 4/18/23 indicated a Skilled Nurse was to visit Patient 1, one time per week. The MSW to visit one time per month, and SC to visit one time a month. On 4/20/23 at 12:05 p.m., an interview was conducted in the agency conference room, with DPCS, he stated the IDG should be signed by the participating staff, but it was not signed. He stated it should be the hospice MD, but previous staff did not sign off on IDG meetings. DPCS stated if its not signed, it's like it was never done. b. On 4/18/23, a review of Patient 2's clinical record indicated Patient 2 was admitted to the hospice agency (HA) on 10/14/22 with a primary diagnosis of hypertensive heart disease (thickening of the blood vessel walls). A review of the POC dated 4/18/23 indicated the skilled nurse was to visit Patient 2 one time per week. A Home Health Aide (HA) was to visit one time per week and the MSW to visit one time per month On 4/20/23 at 12:05 p.m., an interview was conducted in the agency conference room with DPCS, he stated the IDG should be signed by the participating staff but it was not. He stated it should be in hospice MD, but previous staff did not sign off on the IDG meetings. The DPCS stated if its not signed, it's like it was never done. c. On 4/19/23, a review of Patient 3s clinical record indicated Patient 3 was admitted to the hospice agency (HA) on 10/14/22 with a primary diagnosis of hypertensive heart disease (thickening of the blood vessel walls). A review of the POC dated 4/18/23 indicated the skilled nurse was to visit Patient 3 one time per week, and the MSW to visit once a month. On 4/20/23 at 12:05 p.m., an interview was conducted in the agency conference room with DPCS, he stated the IDG should be signed by participating staff but it was not. He stated it should be in hospice MD, but previous staff did not sign off on IDG meetings. DPCS stated if its not signed, it's like it was never done.

Based on observation, interview and record review, the hospice agency failed to ensure the plan of care was followed and revised regarding the use of oxygen to relieve the difficulty in breathing for one of six sampled patients, (Patient 4). This deficient practice can result in the agency not providing appropriate patient care and services necessary to maintain the patient's highest practicable well-being. --- A review of Patient 4's clinical record indicated a start of care (SOC) date of 12/12/2022, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (heart disease). A review of the Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) dated 12/12/2022, indicated Patient 4 was alert and oriented, ambulatory with a cane and a walker, and needed moderate to maximal assistance for the activities of daily living (ADL). Patient 4 had moderate dyspnea at rest and an oxygen saturation (oxygen level in the blood, normal range of 95-100%) rate measured as 94 percent with two liters of oxygen being administered. A review of Patient 4's Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/ Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 12/12/2022, indicated the Registered Nurse (RN) frequency of visits to Patient 4 was for every 14 days or sooner. The Licensed Vocational Nurse (LVN) visits were once per week and the Medical Social Worker (MSW) and Spiritual Counsellor (SC) visits were on initial evaluation then once a month. There was a plan of care developed for the impaired respiratory function related to bronchospasm and airway inflammation as manifested by shortness of breath. One of the interventions indicated was to administer oxygen at two liters per minute. On 4/19/2023, at 10 a.m., during a joint home visit at Patient 4s residence with the Director of Patient Care Services (DPCS), Patient 4 was alert and oriented, and able to communicate well. Patient 4 was receiving oxygen at three point five (3.5) liters per minute via nasal cannula. At 10:05 a.m., after the DPCS checked the patients oxygen saturation, he stated it was 94 percent. During an interview with Patient 4, he stated he had been using oxygen at 3.5 liters per minute 18 hours a day for few months because two liters per minute was not enough for his dyspnea. A review of the POC/IDG from 12/12/2022 to 4/17/2023 indicated there was no documented evidence the IDG team had discussed Patient 4s oxygen administration of 2 liters per minute being not enough nor a revision of the POC. During an interview with the DPCS on 4/20/2023, at 12:25 a.m., he stated the SN should have notified the MD/IDG team about the patients use of oxygen at 3.5 liters per minute, and the plan of care should have been revised accordingly after discussion between the IDG members. A review of the agencys policy and procedure titled ";The Plan of Care" revised in November 2020 indicated the plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver based on ongoing comprehensive assessments of the patient and family/caregiver.

Based on observation, interview and record review, the hospice agency failed to ensure the oxygen supply was coordinated with the hospice agency personnel, and failed to ensure the oxygen was available and accessible at home in case of respiratory distress, for one of six sampled patients, Patient 1. This deficient practice placed Patient 1 at risk for respiratory distress and discomfort when a respiratory crisis occurs. --- On 4/18/2023, a review of Patient 1s clinical record indicated Patient 1 was admitted to the hospice agency (HA) on 3/22/23 with a primary diagnosis of Alzheimers Disease (progressive mental deterioration due to generalized degeneration of the brain). A review of the POC dated 4/18/23 indicated the Skilled Nurse was to visit Patient 1 once per week. The Medical Social Worker (MSW0 was to visit once a month, and the Spiritual Counsellor (SC) was to visit once a month. On 4/19/2023 at 10:30 a.m., an interview was conducted with Registered Nurse (RN) 1 outside of Patient 1s home. RN1 stated the oxygen concentrator was ordered for Patient 1 but is not currently in his home. RN 1 stated it should have been here and I need to follow up with the Director of Patient Care Services (DPCS). RN 1 admitted that this issue was not communicated with DPCS and RN 1 will follow up. During an interview on 4/20/2023 at 12:05 p.m., the DPCS stated the oxygen concentrator for Patient 1 was not available in the patients home, as ordered. RN 1 also that the oxygen concentrator should have been with Patient 1 in case of respiratory distress and Patient 1 will have an immediate access of the oxygen

Based on interview and record review, the hospice agency failed to ensure abnormal vital signs (blood pressure, heart rate, respiratory rate, temperature), for one of six sampled patients (Patient 2) were reported to the physician as per plan of care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers). This deficient practice had the potential to result in complications and delayed interventions when abnormal vital signs are not reported to the physician timely. --- On 4/18/2023, during a review of the clinical record for Patient 2s, the clinical record indicated Patient 2 was admitted to the hospice agency (HA) on 10/14/22 with a primary diagnosis of hypertensive heart disease (thickening of the blood vessel walls). A review of the Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) / interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) review dated 10/14/22 indicated the Skilled Nurse would visit one time per week. It also indicated to report systolic blood pressure outside of the following ranges 160-90 mmHg and diastolic blood pressures (the second number, that measures the pressure in the arteries when the heart rests between beats) .of 90–50 mmHg. A review of Patient 2s visit notes on the following dates: 12/2/22, 12/9/22, 12/23/22, 1/4/23, 2/2/23, 2/9/23, 2/16/23, and 2/20/23, indicated the diastolic blood pressure for Patient 2 was below the reportable range. --MD ORDER?--- There was no documented evidence provided to indicate the medical director (MD) was notified. On 4/20/2023 at 12:05 p.m., an interview was conducted in the agency conference room with THE Director of Patient Care Services (DPCS). The DPCS stated the MD ordered to report vital signs outside of normal parameters, which was not done. When asked, the DPCS stated there was no documentation that the vital signs were ever reported to the MD. During a review of the agencys policy titled, ";Monitoring patients response/reporting to physician", revised November 2020, indicated clinicians will monitor, document, and report the patients response to care and treatment provided on each hospice visit. Clinicians will establish and maintain ongoing communication with the patients physician and the hospice medical director to ensure safe and appropriate care for the patient. .

Based on interview and record review, the hospice agency 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), including the Medical Director, communicated with the patient's' primary care physician to verify the patient's hospice care eligibility, for two of six sampled patients (Patient 5, 6). This deficient practice resulted in certifying patients for hospice (terminally ill patients with 6 months or less to live) services without clinical evidence and documentation to support the diagnoses, and provided hospice care and services to patients who were not hospice qualified. --- a. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of hypertensive heart disease without heart failure (heart disease). A review of the Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 5 was alert and oriented, was ambulatory using a cane and walker, needed moderate assistance in the activities of daily living except in feeding (needed minimal/supervision). Patient 5 could take approximately 40 steps before becoming exhausted and had mild dyspnea with moderate exertion. Patient 5 was not on oxygen therapy, and her oxygen saturation was 96 percent on room air. Patient 5 did not have weight loss in the past six months, had adequate fluid intake, and her membrane was moist and Patient 5 had fairly good skin turgor. A review of the "Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) / Interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker (MSW) visit was once a month. The Spiritual counselor (SC) and the volunteer service was declined. There was no indication whether the hospice aide visit was declined or not. A review of the form titled, "LCD Hospice Eligibility Determination" (LCD, Local Coverage Determination, an assessment to determine patient's eligibility for hospice services) of "Heart Disease," dated 10/20/2022, indicated the sections for "Untreatable condition" and "New York Heart Association Classification (NYHA, classification that provides a simple way of classifying the extent of heart failure) must be met to determine patient's eligibility for hospice services. The form indicated Patient 5 met the criteria for "Untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV, patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation supporting Patient 5 met the criteria for "Untreatable condition" and "NYHA classification" for "NYHA Class IV level". A review of the clinical record indicated there was no documented evidence Patient 5 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," (the document showed a physician certified a patient's eligibility for hospice benefit) for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 5's terminal diagnosis was hypertensive heart disease without heart failure. It indicated Patient 5 was alert and oriented, ambulatory with walker or a cane, could take approximately 40 steps before becoming exhausted and becomes SOB with moderate exertion. Patient 5s oxygen saturation was 96 percent on room air. Patient 5 did not have weight loss in the past six months, had adequate fluid intake, and her membrane was moist and had fairly good turgor. A review of the Discharge Summary indicated Patient 5 was hospitalized on 3/31/2023, and Patient 5s care was ended on 3/31/2023. The summary indicated Patient 5s symptoms were well managed with the hospice interventions, medications and a plan of care, and remained with a steady decline during her care with the agency. On 4/20/2023, at 10:50 a.m., the Surveyor called Patient 5s number on record and Patient 5s caregiver (CG)/Family member 2 (FM2) answered the phone call. During the telephone interview, Patient 5s CG/FM 2 stated Patient 5 could not communicate with the Surveyor because Patient 5 uses non dominant language. FM 2 stated she was not aware that the hospice service was for the person whose life expectancy was less than six months and did not know what hospice meant. FM 2 stated Patient 5 should have not received the hospice service because Patient 5 was not dying nor had been told that Patient 5 had six months or less to live. On 4/19/2023, at 12 p.m., during a telephone interview with Physician 1 who had been Patient 52 primary physician (PCP) since 7/9/2014, Physician 1 stated she did not refer Patient 5 to the hospice agency because Patient 5 did not have any terminal illness and was not eligible to receive hospice services. PCP 1 also stated, nobody from the hospice agency had communicated with her regarding Patient 5s enrollment to the hospice agency, nor she did know Patient 5 had been enrolled with the hospice agency. Physician 1 stated she had not communicated with Physician 2 and did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at12:15 p.m., the DPCS stated he was not able to find the documented evidence Patient 5 met the criteria for LCD eligibility, and any supporting document that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course, such as test result, and the consultation from Patient 5s primary care physician. b. A review of Patient 6's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (heart disease). A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was atherosclerotic heart disease. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 6 was alert and oriented, was ambulatory without using a cane and walker, needed minimal supervision for all activities of daily living (ADL) but needed moderate assistance in toileting. Patient became to have shortness of breath (SOB) after moderate activity. Patient 6 was not on oxygen therapy, and his oxygen saturation was measured as 98 percent on room air. Patient 6 did not have significant weight loss in the past six months. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor, the hospice aide service, and the volunteer service was declined. A review of the form titled, "LCD Hospice Eligibility Determination" of "Heart Disease," dated 10/20/2022, indicated that the sections for "Untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV, patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation to support Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level". A review of the clinical record indicated there was no documented evidence Patient 6 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," (the document that showed a physician certified a patient's eligibility for hospice benefit) for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 5's terminal diagnosis was hypertensive heart disease without heart failure. It indicated Patient 6 was alert and oriented, ambulatory without need walker or a cane, becomes SOB with moderate exertion. Patient 6s oxygen saturation was 98 percent on room air. Patient 6 did not have significant weight loss in the past six months. It also indicated the Medical Director had certified that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. On 4/20/2023, at 10:50 a.m., the Surveyor called Patient 6s phone number on record. Patient 6s caregiver (CG)/Family member 2 (FM2) answered the phone call. During a telephone interview with Patient 6s CG/FM 2, she stated Patient 6 could not communicate with the Surveyor because Patient 5 uses a non-dominant language. FM 2 stated she was not aware that the hospice service was for the person whose life expectancy was less than six months and did not know what the term hospice meant. FM 2 stated Patient 6 should have not received the hospice service because Patient 6 was not dying nor had been told Patient 6 had six months or less to live. A review of the Discharge Summary indicated Patient 6 was hospitalized on 3/31/2023, and Patient 6s care was ended on 3/31/2023. It indicated Patient 6s symptoms were well managed with the hospice interventions, medications, and a plan of care, and she remained on a steady decline during her care with the agency. On 4/19/2023, at12 p.m., during a telephone interview with Physician 1 who had been a primary physician (PCP) of Patient 6 since 8/9/2017, the PCP stated she had not referred Patient 6 to the agency because Patient 6 did not have terminal illness and was not eligible to receive hospice service. PCP 1 stated nobody from the hospice agency had communicated with her regarding Patient 6s enrollment to the agency, and she did not know Patient 6 had enrolled with the hospice agency. Physician 1 stated she had not communicated with Physician 2 and she did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at12:15 p.m., he stated he was not able to find the documented evidence Patient 6 met the criteria for LCD eligibility, and the supporting documentation that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course (such as test result, and the consultation from Patient 6s primary care physician). A review of the agencys policy titled ";Admission Criteria and Process" revised in November 2020 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 intermediary Local Coverage Determinations (LCDs). The policy also indicated the agency will admit a patient only on recommendation of the medical director in consultation with or input from, the patients attending physician, if any. 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 provide evidence that the quality assessment and performance improvement (QAPI, a coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI), which are critical to improving the quality of life, and quality of care and services delivered in a healthcare facility) system was formulated and to ensure its program objectives, patient care disciplines, description of how the program will be administered and coordinated, methodology for monitoring and evaluating the quality of care, priorities for resolution of problems, monitoring to determine effectiveness of action, oversight responsibility reports to governing body, and documentation of the review of its own QAPI program were implemented. This deficient practice had the potential to result in the inability of the agency to identify issues, improve health outcomes, patient safety, and quality patient care, and had the potential to affect the care provided to the patients. --- During an interview with the Director of Patient Care Services (DPCS) on 4/20/23, at 4:10 p.m., he stated he was new and had became the DPCS on March 2023 and could not find/provide the evidence a functioning QAPI (QAPI, a coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI), which are critical to improving the quality of life, and quality of care and services delivered in a healthcare facility) program had been maintained. The DPCS stated he could not find/provide QAPI meeting minutes, or any documentation with signatures of core staff who had attended. The DPCS stated previous Medical Director, Administrator and the DPCS are no longer working for the agency. A review of the agencys policy and procedure titled ";Improving organizational performance" revised in November 2020 indicated performance improvement results will be utilized to address problem issues, improve the quality of care and patient safety, and will be incorporated into program planning and process design and modifications. A review of the agencys job description summary for the Director of Patient Care Services indicated the DPCS is responsible for the implementation and monitoring of the organizations quality assessment performance improvement (QAPI) program.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as evidence by: The hospice agency failed to: 1.Ensure patients clinical information were reviewed to ensure the initial certifications for the three of six sampled patients (Patients 1, 5, 6), were accurate. These deficient practices resulted in the agency certifying patients for hospice care, without documentation of clinical evidence to support its terminal illness and had the potential to result in an inappropriate care and services provided to the patients. (Refer to L667) 2.Ensure the medical director completed the ";Physicians Certification for Hospice Benefit" (CTI, illness with a prognosis of having 6 months of life or less) prior to its recertification for continued hospice care and services, for one of six sampled patients, (Patient 4). This deficient practice had the potential that patients who are no longer qualified to receive hospice care will continue with the services and can affect the quality of life for the affected patients. (Refer to L668) 3.Ensure accurate assessment and review of clinical record was conducted to verify patient clinical information necessary for initial certification and recertification of terminal illness for three of six sampled patients (Patients 4, 5, and 6). This deficient practice resulted in the hospice agency recertifying patients without verifying documentation of clinical evidence that support the terminal diagnoses. (Refer to L669) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services. --- .

Based on interview and record review, the hospice agency failed to ensure patients clinical information were reviewed to ensure the initial certifications for the three of six sampled patients (Patients 1, 5, 6), were accurate. These deficient practices resulted in the agency certifying patients for hospice care, without documentation of clinical evidence to support its terminal illness and had the potential to result in an inappropriate care and services provided to the patients. --- b. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of hypertensive heart disease without heart failure. It was indicated in the face sheet that Physician 2 was the referring doctor. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 5 was alert and oriented, was ambulatory using a cane and walker, needed moderate assistance in the activities of daily living except in feeding (needed minimal/supervision). Patient 5 could take approximately 40 steps before becoming exhausted and had mild dyspnea with moderate exertion. Patient 5 was not on oxygen therapy, and her oxygen saturation was measured as 96 percent on room air. Patient 5 did not have weight loss in the past six months, had adequate fluid intake, and her membranes were moist and she had fairly good skin turgor. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor and the volunteer service was declined. There was no indication whether the hospice aide visit was declined or not. A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine a patient's eligibility for hospice services) of "Heart Disease," dated 10/20/2022, indicated the sections for an "Untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine a patient's eligibility for hospice services. The form indicated Patient 5 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation supporting Patient 5 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level." A review of the clinical record indicated there was no documented evidence Patient 5 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," (The document showed a physician certified a patient's eligibility for hospice benefit) for the first 90-day period from 10/20/2022 to 1/17/2023, indicated Patient 5's terminal diagnosis was hypertensive heart disease without heart failure. It indicated Patient 5 was alert and oriented, ambulatory with walker or a cane, could take approximately 40 steps before becoming exhausted and becomes SOB with moderate exertion. Patient 5s oxygen saturation was measured as 96 percent on room air. Patient 5 did not have weight loss in the past six months, had adequate fluid intake, and her membranes were moist and she had fairly good skin turgor. It indicated Patient 5 met the criteria for LCD eligibility, and the Medical Director had certified Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. There was only the previous Medical Directors electronic signature on the CTI. A review of the Discharge Summary indicated Patient 5 was hospitalized on 3/31/2023, and Patient 5s care was ended on 3/31/2023. The Discharge Summary indicated Patient 5s symptoms were well managed with the hospice interventions, medications and a plan of care, and she remained on a steady decline during her care with the agency. On 4/20/2023, at 10:50 a.m., when the Surveyor called Patient 5s number of record, Patient 5s caregiver (CG)/Family member 2 (FM2) answered the phone call. During a telephone interview with Patient 5s CG/FM 2, she stated Patient 5 could not communicate with the Surveyor because Patient 5 uses a non dominant language. FM 2 stated she was not aware the hospice service was for a person whose life expectancy was less than six months, and did not know what hospice meant. FM 2 stated she was told the hospice service was provided at home instead of the patient going to another place to receive care. FM 2 stated Patient 5 should have not received the hospice service because Patient 5 was not dying nor had been told Patient 5 had six months or less to live. FM 2 stated Physician 1 was Patient 6's primary doctor, and she did not know who Physician 2 was. On 4/19/2023, at 12 p.m., during a telephone interview with Physician 1, who had been a primary physician of Patient 5 since 7/9/2014, stated she had not referred Patient 5 to the agency because Patient 5 did not have a terminal illness and was not eligible to receive hospice service. PCP 1 stated nobody from the hospice agency had communicated with her regarding Patient 5s enrollment to the agency, and she did not know Patient 5 had enrolled in the hospice agency. Physician 1 stated She had not communicated with Physician 2 and she did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at12:15 p.m., he stated he was not able to find the documented evidence Patient 5 met the criteria for LCD eligibility, and the supporting documentation that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course, such as test result, and the consultation from Patient 5s primary care physician. The DPCS stated Physician 2 was a "Mobile doctor." During a telephone interview with the current Medical Director (MD) on 4/20/2023, at 12:48 p.m., she stated she became a Medical Director of the hospice agency less than a month ago. The MD stated when the agency admits the patient to the hospice agency, the MD/NP should see the patient (physically or facetime), interview family and patient, communicate with the patients primary physician and review the history and physical from the patients primary physician, review the hospital record (if any), and review the RNs assessment and LCD assessment. c. A review of Patient 6's (Patient 6 was Patient 5s family member) electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery. It was indicated in the face sheet that Physician 2 was the referring doctor. A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was hypertensive heart disease without heart failure. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 6 was alert and oriented, was ambulatory without using a cane and walker, needed minimal supervision for all activities of daily living (ADL) but needed moderate assistance in toileting. Patient 6 had shortness of breath (SOB) after moderate activity. Patient 6 was not on oxygen therapy, and his oxygen saturation was 98 percent on room air. Patient 6 did not have significant weight loss in the past six months. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor, the hospice aide service, and the volunteer service was declined. A review of the form titled, "LCD Hospice Eligibility Determination" of "Heart Disease," dated 10/20/2022, indicated the sections for "Untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine the patient's eligibility for hospice services. The form indicated Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation to support Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level." A review of the clinical record indicated there was no documented evidence Patient 6 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," (CTI - a document that showed a physician certified a patient's eligibility for hospice benefit) for the first 90-day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was atherosclerotic heart disease of native coronary artery. It indicated Patient 6 was alert and oriented, ambulatory without need of walker or a cane, and became SOB with moderate exertion. Patient 6s oxygen saturation was measured as 98 percent on room air. Patient 6 did not have significant weight loss in the past six months. It indicated Patient 6 met the criteria for LCD eligibility, and the Medical Director had certified that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. There was only the previous Medical Directors electronic signature on the CTI. On 4/20/2023, at 10:50 a.m., when the Surveyor called Patient 6s number of record, Patient 6s caregiver (CG)/Family member 2 (FM2) answered the phone call. During a telephone interview with Patient 6s CG/FM 2, she stated Patient 6 could not communicate with the Surveyor because Patient 5 uses non dominant language. FM 2 stated she was not aware the hospice service was for the person whose life expectancy was less than six months, and did not know what the hospice meant. FM 2 stated she was told the hospice service was provided at home instead of the patient going to other place to receive care. FM 2 stated Patient 6 should have not received the hospice service because Patient 6 was not dying nor had been told that Patient 6 had 6 months or less to live. FM 2 stated Physician 1 was Patient 6's primary doctor, and she did not know who Physician 2 was. A review of the Discharge Summary indicated Patient 6 was hospitalized on 3/31/2023, and Patient 6s care was ended on 3/31/2023. It indicated Patient 6s symptoms were well managed with the hospice interventions, medications and a plan of care, and she was remained on a steady decline during his care with the agency. On 4/19/2023, at12 p.m., during a telephone interview with Physician 1 who had been a primary physician (PCP) of Patient 6 since 8/9/2017, Physician 1 stated she had not referred Patient 6 to the agency because Patient 6 did not have a terminal illness and was not eligible to receive hospice service. PCP 1 stated nobody from the hospice agency had communicated with her regarding Patient 6s enrollment to the agency, and she did not know Patient 6 had enrolled with the hospice agency. Physician 1 stated she had not communicated with Physician 2 and she did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at12:15 p.m., he stated he was not able to find the documented evidence Patient 6 met the criteria for LCD eligibility, and the supporting documentation that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course (such as test result, and the consultation from Patient 6s primary care physician). The DPCS stated Physician 2 was a "Mobile doctor." There was a ";Termination Agreement" signed by the previous Medical Director which indicated the previous Medical Director would terminate the ";Professional Services Agreement, Medical Director" as of March 5, 2023. During a telephone interview with the current Medical Director (MD) on 4/20/2023, at 12:48 p.m., she stated she became a Medical Director of the hospice agency less than a month ago. The MD stated when the agency admits a patient to the hospice agency, the MD/NP should see the patient (physically or via facetime), interview family and patient, communicate with the patients primary physician and review the history and physical from the patients primary physician, review the hospital record (if any), review the RNs assessment and LCD assessment. A review of the agencys policy titled ";Admission Criteria and Process" revised in November 2020 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). The policy indicated the agency will admit a patient only on recommendation of the medical director in consultation with or input from, the patients attending physician, if any. 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. A review of the agencys policy and procedure titled ";Certification of Terminal Illness" revised in November 2020 indicated as follows: At the time of admission to hospice, the hospice Medical Director or the patients attending physician will complete a certification narrative that reflects the patients individual circumstances based on: his/her review of the patients medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms). a. On 4/18/23, a review of Patient 1s clinical record indicated Patient 1 was admitted to the hospice agency (HA) on 3/22/23 with a primary diagnosis of Alzheimers Disease (progressive mental deterioration due to generalized degeneration of the brain). A review of the POC dated 4/18/23 indicated the Skilled Nurse was to visit Patient 1 one time per week. The MSW to visit one time a month, and the SC was to visit one time a month. A review of the agencys document entitled face to face encounter dated 3/15/23 indicated Patient 1 weighed 199 lbs. A review of the agencys document entitled comprehensive nursing assessment dated 3/22/23 indicated Patient 1 weighed 133 lbs. On 4/20/23 at 12:05 p.m., an interview was conducted in the agency conference room, with the DPCS, he stated a history and physical, dated 3/15/23, documented a weight of 199 lbs for Patient 1 and is not congruent with the initial assessment, dated 3/22/23, which documented a weight of 133 lbs for Patient 1. The DPCS stated this assessment of weight is not correct.

Based on observation, interview and record review, the hospice agency failed to ensure the medical director completed the ";Physicians Certification for Hospice Benefit" (CTI, illness with a prognosis of having 6 months of life or less) prior to its recertification for continued hospice care and services, for one of six sampled patients, (Patient 4). This deficient practice had the potential that patients who are no longer qualified to receive hospice care will continue with the services and can affect the quality of life for the affected patients. --- A review of Patient 4's clinical record indicated a start of care (SOC) date of 12/12/2022, with a primary diagnosis atherosclerotic heart disease of native coronary artery (heart disease). A review of the Comprehensive Nursing Assessment (in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) dated 12/12/2022 indicated Patient 4 was alert and oriented, ambulatory with a cane and a walker, and needed moderate to maximal assistance for the activities of daily living (ADL). Patient 4 had moderate dyspnea at rest and oxygen saturation (the amount of oxygen in the bloodstream with normal range of 95-100%) rate was 94 percent with two (2) liters of oxygen administration. A review of Patient 4's Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 12/12/2022, indicated the Registered Nurse (RN) frequency of visits every 14 days or sooner. The Licensed Vocational Nurse visits were once per week and the Medical Social Worker (MSW) and Spiritual Counsellor (SC) visits were on initial evaluation then once a month. On 4/19/2023, at 10 a.m., during a joint home visit to Patient 4s residence with the Director of Patient Care Services (DPCS), Patient 4 was alert and oriented, and able to communicate well. Patient 4 was receiving oxygen at 3.5 liters per minute via nasal cannula. A review of the ";Physicians Certification for Hospice Benefit" (CTI, illness with a prognosis of having 6 months of life or less) from 3/12/2023 to 5/10/2023 indicated the space for the physicians narrative was left blank. The previous Medical Directors name was typed on the form, but the space for the signature and date was left blank. During an interview with the Director of Patient Care Services (DPCS) on 4/20/2023, at 2:40 p.m., the DPCS stated Patient 4s ";Physicians Certification for Hospice Benefit" from 3/12/2023 to 5/10/2023 was not conducted yet. The DPCS also stated the ";Physicians Certification for Hospice Benefit (CTI)" should have been completed before the recertification of hospice benefit started. The ";Termination Agreement" signed by the previous Medical Director indicated the previous Medical Director would terminate the ";Professional Services Agreement, Medical Director" as of March 5, 2023. During a telephone interview with the current Medical Director (MD) on 4/20/2023, at 12:48 p.m., the MD stated she became a Medical Director of the hospice agency less than a month ago. The current MD stated when the agency recertifies the hospice service, the MD/NP should sign, ";see the patient (physically or facetime), interview family and patient, review medical documentation including the Registered Nurses (RN) assessment, SN notes, LCD assessment, and the Medical Director should sign the ";Physicians Certification for Hospice Benefit (CTI)" before the benefit begins A review of the agencys policy and procedure titled ";Certification of Terminal Illness", revised in November 2020, indicated 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.

Based on observation, interview and record review, the hospice agency failed to ensure accurate assessment and review of clinical record was conducted to verify patient clinical information necessary for initial certification and recertification of terminal illness for three of six sampled patients (Patients 4, 5, and 6). This deficient practice resulted in the hospice agency recertifying patients without verifying documentation of clinical evidence that support the terminal diagnoses. --- a. A review of Patient 4's clinical record indicated a start of care (SOC) date of 12/12/2022, with a primary diagnosis atherosclerotic heart disease of native coronary artery (heart disease). A review of the Comprehensive Nursing Assessment (in-person clinical assessment of the patient's physical, functional, mental, psychosocial, and cognitive status to identify the needs of the patient and caregiver that will be addressed by the home health agency's services) dated 12/12/2022, indicated Patient 4 was alert and oriented, ambulatory with a cane and a walker, and needed moderate to maximal assistance for the activities of daily living (ADL). Patient 4 had moderate dyspnea at rest and oxygen saturation rate (the amount of oxygen in the bloodstream with normal range of 95-100%) was measured as 94 percent at two liters of oxygen administration. A review of Patient 4's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) /Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 12/12/2022, indicated the Registered Nurse (RN) frequency of visits for every 14 days or sooner. The Licensed Vocational Nurse (LVN) visits were once per week and the Medical Social Worker (MSW) and Spiritual Counsellor (SC) visits were on initial evaluation and then once a month. On 4/19/2023, at 10 a.m., during a joint home visit to Patient 4s residence with the Director of Patient Care Services (DPCS), Patient 4 was alert and oriented, and able to communicate well. Patient 4 was receiving oxygen at 3.5 liters per minute via nasal cannula. A review of the ";Physicians Certification for Hospice Benefit (CTI)" from 3/12/2023 to 5/10/2023 indicated the space for the physicians narrative was left blank. There was previous Medical Directors name was typed in the form, but the space for the signature and date was left blank. During an interview with the Director of Patient Care Services (DPCS) on 4/20/2023, at 2:40 p.m., he stated Patient 4s ";Physicians Certification for Hospice Benefit (CTI)" from 3/12/2023 to 5/10/2023 was not conducted yet. He stated the ";Physicians Certification for Hospice Benefit" (CTI, illness with a prognosis of having 6 months of life or less) should have been completed before the recertification of hospice benefit started. During a telephone interview with the Current Medical Director (MD) on 4/20/2023, at 12:48 p.m., she stated she became a Medical Director of the hospice agency less than a month ago. The current MD stated when the agency recertified the hospice benefit, the MD/NP (Nurse Practitioner) should see the patient physically or via facetime, interview family and patient, review the medical record including the RN assessment, SN Note, and the Medical Director should sign the CTI before the benefit begins. b. A review of Patient 5's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of hypertensive heart disease without heart failure. It indicated that Physician 2 was the referring doctor. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 5 was alert and oriented, was ambulatory using a cane and walker, needed moderate assistance in the activities of daily living except in feeding (needed minimal/supervision). Patient 5 could take approximately 40 steps before becoming exhausted and had mild dyspnea with moderate exertion. Patient 5 was not on oxygen therapy, and her oxygen saturation was measured as 96 percent on room air. Patient 5 did not have weight loss in the past six months, had adequate fluid intake, and her membrane was moist and had fairly good skin turgor. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor and the volunteer service was declined. There was no indication whether the hospice aide visit was declined or not. A review of the form titled, "LCD Hospice Eligibility Determination" (LCD, Local Coverage Determination, an assessment to determine a patient's eligibility for hospice services) of "Heart Disease," dated 10/20/2022, indicated the sections for an "Untreatable condition" and "New York Heart Association (NYHA, classification that provides a simple way of classifying the extent of heart failure) classification" must be met to determine a patient's eligibility for hospice services. The form indicated Patient 5 met the criteria for "Untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation supporting Patient 5 met the criteria for an "untreatable condition" and "NYHA classification" for "NYHA Class IV level." A review of the clinical record indicated there was no documented evidence Patient 5 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 10/20/2022 to 1/17/2023, indicated Patient 5's terminal diagnosis was hypertensive heart disease without heart failure. It indicated Patient 5 was alert and oriented, ambulatory with walker or a cane, could take approximately 40 steps before becoming exhausted and becomes SOB with moderate exertion. Patient 5s oxygen saturation was measured as 96 percent on room air. Patient 5 did not have weight loss in the past six months, had adequate fluid intake, and her membranes were moist, and she had fairly good skin turgor. It indicated Patient 5 met the criteria for LCD eligibility, and the Medical Director had certified that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. The previous Medical Directors electronic signature was on the CTI. A review of the Discharge Summary indicated Patient 5 was hospitalized on 3/31/2023, and Patient 5s care ended on 3/31/2023. It indicated Patient 5s symptoms were well managed with the hospice interventions, medications and a plan of care, and she remained on a steady decline during her care with the agency. On 4/20/2023, at 10:50 a.m., when the Surveyor called Patient 5s number of record, Patient 5s caregiver (CG)/Family member 2 (FM2) answered the phone call. During a telephone interview with Patient 5s CG/FM 2, she stated Patient 5 could not communicate with the Surveyor because Patient 5 uses non dominant language. FM 2 stated she was not aware that the hospice service was for the person whose life expectancy was less than six months and did not know what hospice meant. FM 2 stated Patient 5 should have not received the hospice service because Patient 5 was not dying nor had been told that Patient 5 had six months or less to live. On 4/19/2023, at 12 p.m., during a telephone interview with Physician 1 who had been the primary physician of Patient 5 since 7/9/2014, stated she had not referred Patient 5 to the agency because Patient 5 did not have terminal illness and was not eligible to receive hospice service. Physician 1 stated nobody from the hospice agency had communicated with her regarding Patient 5s enrollment to the agency and did not know Patient 5 had enrolled in the hospice agency. Physician 1 stated she had not communicated with Physician 2 and she did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at 12:15 p.m., the DPCS stated he was not able to find the documented evidence Patient 5 met the criteria for LCD eligibility, and the supporting documentation that Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course, such as test result, and the consultation from Patient 5s primary care physician. The DPCS stated Physician 2 was a "Mobile doctor". The ";Termination Agreement" signed by the previous Medical Director which indicated the previous Medical Director would terminate the ";Professional Services Agreement, Medical Director" as of March 5, 2023. During a telephone interview with the Current Medical Director (MD) on 4/20/2023, at 12:48 p.m., she stated she became a Medical Director of the hospice agency less than a month ago. The MD stated when the agency admits the patient to the hospice agency, the MD/NP should see the patient physically or via facetime, interview family and patient, communicate with the patients primary physician and review the history and physical from the patients primary physician, review the hospital record (if any), and review the RNs assessment and LCD assessment. c. A review of Patient 6's electronic clinical record indicated a start of hospice care date of 10/20/2022, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery. A review of the "Physician's Certification for Hospice Benefit," for the first 90-day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was hypertensive heart disease without heart failure. It was indicated that Physician 2 was the referring doctor. A review of the Comprehensive Nursing Assessment by the Registered Nurse (RN), dated 10/20/2022, indicated Patient 6 was alert and oriented, was ambulatory without using a cane and walker, needed minimal supervision for all activities of daily living (ADL) but needed moderate assistance in toileting. Patient 6 became to have shortness of breath (SOB) after moderate activity. Patient 6 was not on oxygen therapy, and his oxygen saturation was measured as 98 percent on room air. Patient 6 did not have significant weight loss in the past six months. A review of the "Plan of Care (POC)/Interdisciplinary group (IDG) Review," dated 10/31/2022, indicated the Licensed Vocational Nurse (LVN) visit frequency was once a week. The Registered Nurse (RN) and the medical social worker visit was once a month. The Spiritual counselor, the hospice aide service, and the volunteer service was declined. A review of the form titled, "LCD Hospice Eligibility Determination" of "Heart Disease," dated 10/20/2022, indicated the sections for "Untreatable condition" and "New York Heart Association (NYHA) classification" must be met to determine patient's eligibility for hospice services. The form indicated Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level" (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occur at rest). A review of the clinical record indicated there was no documentation supporting Patient 6 met the criteria for an "Untreatable condition" and "NYHA classification" for "NYHA Class IV level". A review of the clinical record indicated there was no documented evidence Patient 6 met the criteria for LCD eligibility. A review of the "Physician's Certification for Hospice Benefit," for the first 90-day period from 10/20/2022 to 1/17/2023, indicated Patient 6's terminal diagnosis was atherosclerotic heart disease of native coronary artery. It indicated Patient 6 was alert and oriented, ambulatory without need walker or a cane, becomes SOB with moderate exertion. Patient 6s oxygen saturation was 98 percent in room air. Patient 6 did not have significant weight loss in the past 6 months. It indicated Patient 6 met the criteria for LCD eligibility, and the Medical Director had certified that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. There was only the previous Medical Directors electronic signature on the CTI. On 4/20/2023, at 10:50 a.m., when the Surveyor called Patient 6s number on the record, Patient 6s caregiver (CG)/Family member 2 (FM2) answered the phone call. During a telephone interview with Patient 6s CG/FM 2, she stated Patient 6 could not communicate with the Surveyor because Patient 6 uses non dominant language. FM 2 stated she was not aware the hospice service was for the person whose life expectancy was less than six months, and did not know what hospice meant. FM 2 stated Patient 6 should have not received the hospice service because Patient 6 was not dying nor had been told that Patient 6 had six months or less to live. A review of the Discharge Summary indicated Patient 6 was hospitalized on 3/31/2023, and Patient 6s care was ended on 3/31/2023. It indicated Patient 6s symptoms were well managed with the hospice interventions, medications and a plan of care, and she remained on a steady decline during her care with the agency. On 4/19/2023, at12 p.m., during a telephone interview with Physician 1 who had been a primary physician (PCP) of Patient 6 since 8/9/2017, Physician 1 stated she had not referred Patient 6 to the agency because Patient 6 did not have a terminal illness and was not eligible to receive hospice service. Physician 1 stated nobody from the hospice agency had communicated with her regarding Patient 6s enrollment to the agency, and she did not know Patient 6 had enrolled with the hospice agency. Physician 1 stated she had not communicated with Physician 2 and she did not even know who Physician 2 was. During an interview with the Director of Patient Care services (DPCS) on 4/20/2023, at 12:15 p.m., he stated he was not able to find the documented evidence Patient 6 met the criteria for LCD eligibility, and the supporting documentation that Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course (such as test result, and the consultation from Patient 6s primary care physician). The DPCS stated Physician 2 was a "Mobile doctor". The ";Termination Agreement" signed by the previous Medical Director which indicated the previous Medical Director would terminate the ";Professional Services Agreement, Medical Director" as of March 5, 2023. During a telephone interview with the current Medical Director (MD) on 4/20/2023, at 12:48 p.m., she stated she became a Medical Director of the hospice agency less than a month ago. The MD stated when the agency admits the patient to the hospice agency, the MD/NP should see the patient (physically or via facetime), interview family and patient, communicate with the patients primary physician and review the history and physical from the patients primary physician, review the hospital record (if any), and review the RNs assessment and LCD assessment. The current MD stated the Medical Director should ensure the hospice patients' eligibility and oversee the agency's operation. A review of the agencys policy titled ";Admission Criteria and Process" revised in November 2020 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 intermediary Local Coverage Determinations (LCDs). A review of the agencys policy and procedure titled ";Certification of Terminal Illness" revised in November 2020 indicated as follows: At the time of admission to hospice, the hospice Medical Director or the patients attending physician will complete a certification narrative that reflects the patients individual circumstances based on his/her review of the patients medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms). A review of the agencys policy titled ";Professional Services Agreement for Medical Director" revised in November 2020 indicated the duties and responsibilities of the Medical Director will include, but not be limited to providing overall medical direction to the program including supervision of all hospice physician employees and contract hospice physician, and reviewing the patients medical eligibility for hospice services and providing written certification of the terminal illness for all subsequent benefit periods.