Every finding on record at A Miracle Hospice, Inc.

Based on interview and record review, the Hospice Agency (HA) failed to ensure four of nine sampled patients (Patient 8, Patient 10, Patient 11, and Patient 15) received Patient Rights information in their preferred language they understand. This failure had the potential to result in the patient not being aware of his rights and responsibilities while receiving hospice services. --- Findings: A record review of Patient 8's ";Personal Information" indicated a Start of Care date of 4/12/2023 with a primary diagnosis of chronic ischemic heart disease (heart weakening caused by reduce blood flow to the heart). A record review of Patient 10's ";Personal Information" indicated a Start of Care date of 11/12/2022 with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). The record further indicated the primary language was Armenian. A record review of Patient 11's ";Personal Information" indicated a Start of Care date of 5/5/2022 with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). The record further indicated the primary language was Armenian. A record review of Patient 15's ";Personal Information" indicated a Start of Care date of 3/22/23, with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). The record further indicated the primary language was Armenian. During a concurrent interview and record review on 7/6/2023, at 10:30 a.m. with the Owner (OW) of the Hospice Agency (HA) plan of correction. The OW stated that they have not created a recording consent. OW stated that he did not know they wrote that on the plan of correction. OW stated that he did sign the plan of correction, undated. During an interview on 7/6/23, at 11:14 a.m., the intake coordinator (IC) stated the only documents that were translated were the consents. The IC stated the brochure is pending, and the agency has not received it. The IC stated the agency binder, patients receive, and remain at home, are still in English. During an interview on 7/6/23, at 11:23 a.m., the IC stated the Armenian patient population was not in need of literature in their preferred language because the family speaks English and the nurses visiting the patient speak Armenian and English. The IC stated the agency had ordered consents and brochures for patients speaking Farsi and Russian and were still waiting for delivery. During an interview on 7/7/23, at 3:40 p.m., the Director of Patient Care Services and Administrator (DPCS/ADM) stated she was not actively involved in the plan of correction and was ";just observing" the process. During an interview on 7/7/23 at 3:51 p.m., DPCS/ADM stated there was no evidence of the logs or audits done to correct the deficient practices. A review of the Hospice undated Plan of Correction-POC (a document explaining how the agency will correct the deficient practice), indicated the agency implemented the use of patient handbook, literatures, brochures, and patient informed consent in Spanish translation to effectively communicate with the patient or family. The agency did not indicate in the POC what corrective actions would be done for patients whose primary language was not English.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participation for Initial and Comprehensive Assessments of Patients was met as evidenced by: 1. The HA staff failed to conduct an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for four of nine sample selected patients (Patient 9, Patient 10, Patient 11, and Patient 16). (Refer to L 522). 2. The HA failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) complete the comprehensive assessment no later than 5 calendar days after election for one of nine sampled patients (Patient 16). (Refer to L 523). 3. The HA failed to ensure the comprehensive assessment identified the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that addressed the hospice patient's well-being, comfort, and dignity throughout the dying process for three of nine patients (Patient 9, Patient 10, and Patient 15). (Refer to L 524). 4. The HA staff failed to review all medications the patients were taking and update the medication profiles with the currently used medications for two of nine sample selected patients (Patient 15 and Patient 16). The patients were at risk for medication errors and adverse drug reactions. (Refer to L 530). 5. The HA failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met and updated the comprehensive assessment at least every 15 days for five of nine sample selected patients (Patient1, Patient 3, Patient 4, Patient 11, and Patient 15). (Refer to L 533). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Initial and Comprehensive Assessment of Patients to ensure highest quality of patient care are provided to patients certified to receive the hospice services. --- .

Based on interview and record review the Hospice Agency (HA) staff failed to conduct an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for four of nine sample selected patients (Patient 9, Patient 10, Patient 11, and Patient 16). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- Findings: a. A record review of Patient 9's ";Personal Information" indicated a Start of Care date of 7/7/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During an interview on 7/7/23, at 3:55 p.m., the Director of Patient Care Services and Administrator (DPCS/ADM) stated the doctor needed to document a narrative to indicate the reason for the patient needing hospice care. During an interview on 7/7/23, at 4:07 p.m., the DPCS/ADM stated a comprehensive assessment was to be completed initially on admission and every 3 months. The DPCS/ADM stated a comprehensive assessment was important because if there was a change in the patient condition, the doctor needed to be informed. A review of Patient 9s electronic medical record (EMR) indicated the last comprehensive assessment was done on 4/27/23. A comprehensive assessment was not completed for the following certification period beginning on 7/2/23. A review of Patient 9s record titled, ";Physicians Certification for Hospice Benefit", for certification period 7/2/23 to 8/30/23, did not indicate a doctor had documented the reasons why Patient 9 should continue hospice care. The document was not signed by a doctor. The HA continued to provide hospice services without the doctor certifying Patient 9 for hospice care. b. A record review of Patient 10's ";Personal Information" indicated a Start of Care date of 11/12/2022 with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). A review of Patient 10s EMR indicated the last comprehensive assessment was done on 4/29/23. A comprehensive assessment was not completed for the current certification period. c. A record review of Patient 11's ";Personal Information" indicated a Start of Care date of 5/5/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). A review of Patient 11s record titled, ";Physicians Certification for Hospice Benefit", for certification period 6/29/23 to 8/27/23, did not indicate a doctor had documented the reasons why Patient 11 should continue hospice care. The document was not signed by a doctor. The HA continued to provide hospice services without the doctor certifying Patient 11 for hospice care. d. A record review of Patient 16's ";Personal Information" indicated a Start of Care date of 5/1/2023 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a record review of Patient 16s ";Comprehensive Nursing Assessment" dated 5/1/2023, indicated Patient 16 had poor appetite and was incontinent of bowel and bladder. During a joint home visit on 7/6/2023, at 2:50 p.m., to Patient 16s home with License Vocational Nurse 2 (LVN2), Patient 16 was noted fully dressed, lying on bed under blankets. When Patient 16 saw LVN2 walked in, patient attempted to get out of bed. LVN2 told the Patient 16 something in another language, then Patient 16 returned to the lying position on her bed. Patient 16s daughter/care giver (CG1) stated Patient 16 was on hospice due to not being able to dress or feed herself, ";I cant do anything for her". CG1 stated that Patient 16 has been on hospice for more than a year. CG1stated that the hospice physician saw the Patient 16 about 6-7 months ago. CG1 stated that the Patient 16 does not use diapers, ";she uses pads, she is able to tell me when she has to use the restroom". CG1 stated that the patient eats well. CG1 stated that the patient was allergic to eggplant, tomato, and berries. During an interview on 7/7/23, at 3:40 p.m., the Director of Patient Care Services and Administrator (DPCS/ADM) stated she was not actively involved in the plan of correction and was ";just observing" the process. During an interview on 7/7/23, at 3:51 p.m., DPCS/ADM stated there was no evidence of the logs or audits done to correct the deficient practices. A review of the Hospice undated Plan of Correction (a document explaining how the agency will correct the deficient practice), indicated a use of an admission checklist to ensure the following were present in the patients record: · A written or verbal orders for the referral to hospice, evidence of consultation prior to initiation of services. · A History and Physical or any pertinent information to support hospice criteria from the referring source. · No certification of Terminal Illness must be signed or approved for hospice service without supporting documents. · Modification of informed consent for hospice admission to include voice recording of the entire explanation of hospice service and benefits. The record also indicated the Director of Nurses would perform weekly review of all charts to ensure hospice criteria was met. The record further indicated the Director of Patient Care Services was ultimately responsible for all corrective actions and ongoing compliance.

Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) complete the comprehensive assessment no later than 5 calendar days after election for one of nine sampled patients (Patient 16). This failure had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- Findings: During a record review of Patient 16's ";Personal Information" indicated a Start of Care date of 5/1/2023 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a record review on 7/7/2023, at 11:40 a.m. of Patient 16s Electronic Medical Record (EMR), the EMR indicated form titled ";POC/IDG (Plan of Care/Interdisciplinary Group) Review" dated 5/1/2023 was not signed by the Medical Doctor 1 (MD1) or Medical Social Worker (MSW). During a record review on 7/7/2023, at 11:42 a.m. of Patient 16s EMR, the EMR indicated form titled ";POC/IDG Review" dated 5/4/2023 was not signed by the Medical Doctor 1 (MD1) or Medical Social Worker (MSW). During an interview on 7/7/23, at 3:40 p.m., the Director of Patient Care Services and Administrator (DPCS/ADM) stated she was not actively involved in the plan of correction and was ";just observing" the process. During an interview on 7/7/23, at 3:51 p.m., DPCS/ADM stated there was no evidence of the logs or audits done to correct the deficient practices. During an interview on 7/7/2023, at 5;16 p.m., with the Director of Patient Care Services Designee (DD), the DD stated that the first IDG meeting should be completed in the first week by all members to know the patients condition. A review of the Hospice undated Plan of Correction (a document explaining how the agency will correct the deficient practice), indicated the agency assigned a nurse to visit all active patients to ensure comprehensive assessments were re-evaluated and completed, ensure completion of the comprehensive assessment by the interdisciplinary group within 5 calendar days. The record also indicated the Director of Patient Care Services was ultimately responsible for all corrective actions and ongoing compliance.

Based on interview and record review the Hospice Agency (HA) failed to ensure the comprehensive assessment identified the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that addressed the hospice patient's well-being, comfort, and dignity throughout the dying process for three of nine patients (Patient 9, Patient 10, and Patient 15). This failure had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- Findings: During a record review of Patient 9's ";Personal Information" indicated a Start of Care date of 7/7/2022 with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). A review of Patient 9s electronic medical record (EMR) indicated the last spiritual assessment was done on 11/4/22. No other notes in the EMR to indicate the spiritual needs were assessed. A review of Patient 9s record titled, ";POC Summary", dated 7/6/23, indicated Patient 9 had declined spiritual care services. However, the record indicated the service would continue to be offered. A record review of Patient 10's ";Personal Information" indicated a Start of Care date of 11/12/2022 with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). A review of Patient10s EMR indicated the last spiritual assessment was done on 11/13/22. No other notes were present in the EMR to indicate the spiritual needs were assessed. A review of Patient 10s record titled, ";POC Summary", dated 7/6/23, indicated P10 had declined spiritual care services. However, the record indicated the service would continue to be offered. A record review of Patient 15's ";Personal Information" indicated a Start of Care date of 3/22/23, with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). A review of Patient 15s EMR indicated the last spiritual assessment was done on 3/23/23. No other notes were present in the EMR to indicate the spiritual needs were assessed. A review of Patient 15s record titled, ";POC/IDG Review", dated 6/1/23/6/23, indicated the Chaplain would be available for spiritual needs of the patient. During an interview on 7/7/23, at 3:40 p.m., the Director of Patient Care Services and Administrator (DPCS/ADM) stated she was not actively involved in the plan of correction and was ";just observing" the process. During an interview on 7/7/23, at 3:51 p.m., DPCS/ADM stated there was no evidence of the logs or audits done to correct the deficient practices. A review of the HAs undated Plan of Correction (a document explaining how the agency will correct the deficient practice), indicated the agency would ensure all services (MSW, Chaplain, Nursing, volunteer, and Bereavement) were offered initially by the nurse or social worker and again offered no less than every 15 days by the nurse when social worker and/or spiritual visits have been declined. The record indicated documentation of the services offered would be in the nursing assessment and in the IDG discussion form. The record also indicated the use of a tracking log to maintain compliance. The record also indicated the Director of Patient Care Services was ultimately responsible for all corrective actions and ongoing compliance.

Based on observation, interview and record review, the Hospice Agency (HA) staff failed to review all medications the patients were taking and update the medication profiles with the currently used medications for two of nine sample patients (Patient 15 and Patient 16). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. --- Findings: During a record review of Patient 15's ";Personal Information" indicated a Start of Care date of 3/22/23, with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During an observation of the home visit on 7/7/23, at 11:42 a.m., Licensed Vocational Nurse (LVN 2) was reviewing medications Patient 15 was taking. LVN 2 was reviewing the medications using a medication profile in Patient 15s folder. During a concurrent interview and record review on 7/7/23, at 11:42 a.m., Patient 15s record titled, ";Current Treatment/Medication/DME List", printed on 7/6/23, was reviewed with LVN 2. The record indicated medication ";Lactulose" (a medication used to relieve constipation) was listed twice. The first ";Lactulose" indicated the dosage to be 30 ml (milliliters-unit of measurement) a day as needed. The second ";Lactulose" indicated the dosage to be 15 ml twice a day as needed. LVN 2 stated she did not know why the medication was listed twice. During a concurrent interview and record review on 7/7/23, at 11:45 a.m., Patient 15s record titled, ";Current Treatment/Medication/DME List", printed on 7/6/23, was reviewed with LVN 2. The record indicated comfort medications (medications used at the end of life, to help relieve symptoms such as pain, anxiety, constipation, excessive salivation) were listed to have been ordered for Patient 15 on 4/7/23. LVN 2 stated the comfort medications were not at Patient 15s home and did not know why they were not there. A record review of Patient 16's ";Personal Information" indicated a Start of Care date of 5/1/2023 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a record review on 7/6/2023, at 2:30 pm., of Patient 16s medication list provided by the Intake Coordinator (IC), the medication list indicated there were orders dated from 2020 to 2023. During a record review on 7/6/2023, at 2:40 pm., of Patient 16s updated medication list provided by IC, the updated medication list indicated there were orders dated 2023. During a joint home visit on 7/6/2023, at 2:50 p.m., with License Vocational Nurse 2 (LVN2) at Patient 16s residence, LVN2 reconciliated the patient's medications to an old medication list. LVN2 attempted to open the agencys Electronic Medical Record but was unable to. LVN2 stated that the medication list should be reconciled every visit and checked for discontinued medication or any changes. During a concurrent interview and record review on 7/6/23, at 2:50 p.m., Patient 16s record titled, ";Current Treatment/Medication/DME List", printed on 7/6/23, was reviewed with LVN 2. The record indicated medication ";Clonidine Hydrochloride 0.1mg (medication used to treat high blood pressure)" was on the list but patient did not have the medication at home. There was a medication bottled labeled ";Hydrocodone 5/325mg" at home, but it was not listed on Patient 16s medication list. LVN2 stated that the list should be reconciled every visit. During a concurrent interview and record review on 7/6/23, at 2:50 p.m., Patient 16s record titled, ";Current Treatment/Medication/DME List", printed on 7/6/23, was reviewed with LVN 2. The record indicated comfort medications (medications used at the end of life, to help relieve symptoms such as pain, anxiety, constipation, excessive salivation) were listed to have been ordered for the patient on 5/1/23. LVN 2 stated the comfort medications were not at Patient 16s home and did not know why they were not there. During an interview on 7/7/23, at 3:40 p.m., the Director of Patient Care Services and Administrator (DPCS/ADM) stated she was not actively involved in the plan of correction and was ";just observing" the process. During an interview on 7/7/23 at 3:51 p.m., DPCS/ADM stated there was no evidence of the logs or audits done to correct the deficient practices. During an interview on 7/7/23, at 4:30 p.m., the Director of Patient Care Services Designee (DD) stated the purpose of comfort medications was in case the patient needed comfort of symptoms. During an interview on 7/7/2023, at 4:15 p.m., with the Director of Patient Care Services/Administrator (DPCS/ADM), DPCS/ADM stated that the medication list is reconciled weekly and during the interdisciplinary meetings, because a patients condition might change. DPCS/ADM stated that the medication list is reconciled to prevent an overdose risk. A review of the HAs undated Plan of Correction (a document explaining how the agency will correct the deficient practice), indicated the agency would ensure medication reconciliation would occur every nursing visit and whenever there is a change of order. The record also indicated a use of a monitoring log to effectively monitor, and case manage patients condition in a timely manner. The record also indicated the Director of Patient Care Services was ultimately responsible for all corrective actions and ongoing compliance

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met and updated the comprehensive assessment at least every 15 days for five of nine sample patients (Patient1, Patient 3, Patient 4, Patient 11 and Patient 15). This deficient practice had potential for harm if patients are prevented from reaching their goals, due to IDG not addressing changes in the patient's condition. --- Findings: A record review of Patient 1's ";Personal Information" indicated a Start of Care date of 9/2/2021 with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure, which increases the workload on the heart inducing structural and functional changes.) During a record review on 7/6/2023, at 11:50 a.m., of Patient 1s Electronic Medical Record (EMR), the EMR indicated there was no Medical Director 1 (MD1) input or signature on the IDG meeting held on 6/29/2023. A record review of Patient 3's ";Personal Information" indicated a Start of Care date of 11/23/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a record review on 7/6/2023, at 11:40 a.m., of Patient 3s Electronic Medical Record (EMR), the EMR indicated there was no MD1 input or signature on the IDG meeting held on 6/29/2023. A record review of Patient 4's ";Personal Information" indicated a Start of Care date of 3/1/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (the buildup of fatty material, called plaque, along the walls of the arteries.) During a record review on 7/6/2023, at 12:06 p.m., of Patient 4s Electronic Medical Record (EMR), the EMR indicated there was no MD1 input or signature on the IDG meeting held on 6/29/2023. During an interview on 7/7/2023, at 4:40 p.m., with the Director of Patient Care Services and Administrator (DPCS/ADM), the DPCS/ADM stated that she signed P4s IDG meeting form dated 6/29/2023 yesterday. DPCS/ADM stated that she did not attend the IDG meeting on 6/29/2023. During an interview on 7/7/2023, at 4:38 p.m., with the Director of Patient Care Services Designee (DD), the DD stated that the IDG meetings are to be done every 15 days to provide updates on patients to all the IDG members. A record review of Patient 10's ";Personal Information" indicated a Start of Care date of 11/12/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). A record review of Patient 10s ";POC Summary", dated 7/6/23, indicated a registered nurse was supposed to see the patient every 14 days for an ongoing comprehensive assessment. A record review of Patient 10s ";Updated Assessment", dated 5/27/23, did not indicate an assessment was done. There was no nursing notes and no signature of the nurse. A record review of Patient 10s ";Updated Assessment", dated 6/10/23, did not indicate an assessment was done. There were no nursing notes. A record review of Patient 10s ";Updated Assessment", dated 6/24/23, did not indicate an assessment was done. There were no nursing notes and no signatures of the nurse. A record review of Patient 11's ";Personal Information" indicated a Start of Care date of 5/5/2022 with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). A record review of Patient 11s audit log (a document that records the date, time, and persons making additions, changes, and/or edits in a medical record), dated 7/5/23 to 7/7/23, indicated the following: a. Record titled ";POC/IDG review" dated 6/29/23 was signed by the Director of Patient Care Services/Administrator (DPCS/ADM) on 7/6/23, the day the representative of the health department arrived at the HA. b. The DPCS/ADM entered notes for the Medical Social Worker (MSW) and Chaplain (CP) in record titled, ";POC/IDG review", dated 6/29/23, on 7/5/23. Previously, nothing was documented. c. The DPCS/ADM edited notes for ";summary discussion" for IDG meeting dated 6/29/23, on 7/6/23. d. The CP signed document titled ";POC/IDG review", for dates 6/1/23, 6/15/23, and 6/29/23, on 7/6/23. Previously, there were no signatures. e. The MSW signed document titled ";POC/IDG review", dated 6/29/23, on 7/6/23. Previously, the document was not signed. f. Previous Employee 2 (PE 2) changed notes for ";summary discussion" for IDG meeting on 6/1/23, on 7/5/23. During an interview on 7/7/23, at 4:34 p.m., the Director of Patient Care Services Designee (DD) stated the IDG members were expected to sign the ";POC/IDG review" document on the date of the IDG meeting, to validate their attendance and input during the meeting. The DD stated the MSW, and CP members were expected to document their own input in the form. A record review of Patient 15's ";Personal Information" indicated a Start of Care date of 3/22/23, with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). During a concurrent interview and record review on 7/7/23, at 4:52 p.m., Patient 15s record titled, ";POC Summary", dated 7/6/23, was reviewed with the Director of Patient Care Services Designee (DD). The record indicated a registered nurse was supposed to see the patient every 14 days for an ongoing comprehensive assessment. The DD stated the nurse was supposed to see the patient on 6/28/23. There was no visit made. DD stated she did not know what happened. A record review of P15s audit log dated 7/5/23 to 7/7/23, indicated the following: a. Record titled ";POC/IDG review" dated 6/29/23 was signed by the DPCS/ADM on 7/6/23, b. The DPCS/ADM entered notes for the MSW and CP in record titled, ";POC/IDG review", dated 6/29/23, on 7/5/23. Previously, nothing was documented. c. The CP signed document titled ";POC/IDG review", for dates 6/1/23, 6/15/23, and 6/29/23, on 7/6/23. Previously, there were no signatures. d. The MSW signed document titled ";POC/IDG review, dated 6/29/23, on 7/6/23. Previously, the document was not signed. e. PE 2, edited document titled ";POC/IDG review", dated 6/1/23, on 7/5/23. During an interview on 7/7/23, at 4:40 p.m., the DPCS/ADM stated she documented on Patient 11 and Patient 15s records because it needed to be completed. The DPCS/ADM stated she did not attend the meeting on 6/29/23 because she was sick but documented on the records because she had the information. During an interview on 7/7/23, at 4:44 p.m., the DPCS/ADM stated PE 2 was making edits in the medical records of Patient 11 and Patient 15 because she was probably completing documentation. During an interview on 7/7/23, at 3:40 p.m., the Director of Patient Care Services and Administrator (DPCS/ADM) stated she was not actively involved in the plan of correction and was ";just observing" the process. During an interview on 7/7/23 at 3:51 p.m., DPCS/ADM stated there was no evidence of the logs or audits done to correct the deficient practices. A review of the HAs undated Plan of Correction (a document explaining how the agency will correct the deficient practice), indicated the agency the use of a recertification process checklist to include: · A history and physical record or any pertinent information to support hospice criteria. · All IDG (interdisciplinary group members) must elect and agree to continue or extend hospice service with signed attendance sheet to support the claim of an eligible hospice patient after thorough review. · No certification of terminal illness must be signed or approved for hospice service without the attached supporting documents and checklist must be completed and signed by a clinician. · Use of a tracking log for all patients. The record also indicated the Director of Patient Care Services was ultimately responsible for all corrective actions and ongoing compliance.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Interdisciplinary group, care planning, and coordination of services was met as evidenced by: 1.The HA failed to ensure the Medical Director (MD), Social Worker (SW), and Chaplain (CP) were included in the interdisciplinary group for five of nine sample patients (Patient 1, Patient 3, Patient 4, Patient 11, and Patient 15). (Refer to L 541). 2. The HA failed to provide a ";Comfort Kit" (a prescribed set of medications that are kept in a patients home in the event of an emergency) for two of nine sampled patients (Patient 15 and Patient 16). (Refer to L 549). 3. The HA failed to ensure all care services furnished followed individualized plans of care (POC – an individualized plan that maps out the needs and services supplied to patient and their care givers) established by the interdisciplinary team (IDT) by not conducting home visits as indicated in the POC two of nine sampled patients (Patient 15 and Patient 16). (Refer to L555). 4. The HA failed to ensure one of nine sampled patients (Patient 16) care giver be provided with the patients plan of care (POC) and their medication profile. (Refer to L558). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for IDG, Care Planning, Coordination of Services to ensure highest quality of patient care are provided to patients certified to receive the hospice services. --- .

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Medical Director (MD), Social Worker (SW), and Chaplain (CP) were included in the interdisciplinary group for five of nine sample patients (Patient 1, Patient 3, Patient 4, Patient 11, and Patient 15). This deficient practice could potentially prevent the patients from reaching their care planning goals. --- A record review of Patient 1's ";Personal Information" indicated a Start of Care date of 9/2/2021 with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure, which increases the workload on the heart inducing structural and functional changes.) During a record review on 7/6/2023, at 11:50 a.m., of Patient 1s Electronic Medical Record (EMR), the EMR indicated there was no Medical Director 1 (MD1) input or signature on the IDG meeting held on 6/29/2023. A record review of Patient 3's ";Personal Information" indicated a Start of Care date of 11/23/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a record review on 7/6/2023, at 11:40 a.m., of Patient 3s Electronic Medical Record (EMR), the EMR indicated there was no MD1 input or signature on the IDG meeting held on 6/29/2023. A record review of Patient 4's ";Personal Information" indicated a Start of Care date of 3/1/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (the buildup of fatty material, called plaque, along the walls of the arteries.) During a record review on 7/6/2023 at 12:06 p.m. of Patient 4s Electronic Medical Record (EMR), the EMR indicated there was no MD1 input or signature on the IDG meeting held on 6/29/2023. A record review of Patient 11's ";Personal Information" indicated a Start of Care date of 5/5/2022 with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). A record review of Patient 11s audit log (a document that records the date, time, and persons making additions, changes, and/or edits in a medical record), dated 7/5/23 to 7/7/23, indicated the following: · The DPCS/ADM entered notes for the Medical Social Worker (MSW) and Chaplain (CP) in record titled, ";POC/IDG review", dated 6/29/23, on 7/5/23. Previously, nothing was documented. · The CP signed document titled ";POC/IDG review", for dates 6/1/23, 6/15/23, and 6/29/23, on 7/6/23. Previously, there were no signatures. · The MSW signed document titled ";POC/IDG review, dated 6/29/23, on 7/6/23. Previously, the document was not signed. During an interview on 7/7/23, at 4:34 p.m., the Director of Patient Care Services Designee (DD) stated the IDG members were expected to sign the ";POC/IDG review" document on the date of the IDG meeting, to validate their attendance and input during the meeting. The DD stated the MSW and CP members were expected to document their own input in the form. A record review of Patient 15's ";Personal Information" indicated a Start of Care date of 3/22/23, with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). A record review of Patient 15s audit log dated 7/5/23 to 7/7/23, indicated the following: · The DPCS/ADM entered notes for the MSW and CP in record titled, ";POC/IDG review", dated 6/29/23, on 7/5/23. Previously, nothing was documented. · The CP signed document titled ";POC/IDG review", for dates 6/1/23, 6/15/23, and 6/29/23, on 7/6/23. Previously, there were no signatures. · The MSW signed document titled ";POC/IDG review, dated 6/29/23, on 7/6/23. Previously, the document was not signed. During an interview on 7/7/23, at 4:40 p.m., the DPCS/ADM stated she documented on Patient 11 and Patient 15s records because it needed to be completed. The DPCS/ADM stated she did not attend the meeting on 6/29/23 because she was sick but documented on the records because she had the information. A review of the HAs undated Plan of Correction (a document explaining how the agency will correct the deficient practice), indicated the quality assurance coordinator and nursing supervisor would review each patients chart to validate the content of the IDG meetings. Any deficiencies would be addressed in a timely manner and non-compliance of staff would be addressed. The record also indicated the Director of Patient Care Services was ultimately responsible for all corrective actions and ongoing compliance.

Based on interview and record review the Hospice Agency (HA) failed to provide a "Comfort Kit" (a prescribed set of medications that are kept in a patient's home in the event of an emergency) for two of nine sampled patients (Patient 15 and Patient 16). This failure had the potential to result in patients not receiving their comfort medications when needed to mitigate pain and discomfort. --- Findings: During record review of Patient 15's ";Personal Information" indicated a Start of Care date of 3/22/23, with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a home visit on 7/7/23, at 11:42 a.m., it was observed Licensed Vocational Nurse (LVN 2) was reviewing medications Patient 15 was taking from the patient's medication profile inside the folder. During a concurrent interview and record review on 7/7/23, at 11:45 a.m., Patient 15s record titled, ";Current Treatment/Medication/DME List", printed on 7/6/23, was reviewed with LVN 2. The record indicated comfort medications (medications used at the end of life, to help relieve symptoms such as pain, anxiety, constipation, excessive salivation) were listed to have been ordered for Patient 15 on 4/7/23. LVN 2 stated the comfort medications were not at Patient 15s home and did not know why they were not there. A record review of Patient 16's ";Personal Information" indicated a Start of Care date of 5/1/2023 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a joint home visit on 7/6/2023, at 2:50 p.m., with License Vocational Nurse 2 (LVN2) at Patient 16s residence, LVN2 reconciled the patient's medications from an old medication list. LVN2 attempted to open the agencys Electronic Medical Record but was unable. LVN2 stated that the medication list should be reconciled every visit and check for discontinued medication or any changes. During a concurrent interview and record review on 7/6/23, at 2:50 p.m., Patient 16s record titled, ";Current Treatment/Medication/DME List", printed on 7/6/23, was reviewed with LVN 2. The record indicated comfort medications (medications used at the end of life, to help relieve symptoms such as pain, anxiety, constipation, excessive salivation) were listed to have been ordered for the patient on 5/1/23. LVN 2 stated the comfort medications were not at Patient 16s home and did not know why they were not there. During an interview on 7/7/23, at 4:30 p.m., the Director of Patient Care Services Designee (DD) stated the purpose of comfort medications was in case the patient needed comfort of symptoms. A review of the HAs undated Plan of Correction (a document explaining how the agency will correct the deficient practice), indicated the agency had the nursing supervisor perform on site visits to all active patients to ensure comfort kits were indicated. The record also indicated the use of a monitoring log to effectively monitor, and case manage patients condition in a timely manner. The record also indicated the Director of Patient Care Services was ultimately responsible for all corrective actions and ongoing compliance.

Based on interview and record review the Hospice Agency (HA) failed to ensure all care services furnished followed the individualized plans of care (POC – an individualized plan that maps out the needs and services supplied to patient and their care givers) established by the interdisciplinary team (IDT) for two of nine sampled patients (Patient 15 and Patient 16). This deficient practice resulted in the patients not receiving care/services from the home visits and placed the patients at risk by not being provided care/services when they needed. --- Findings: During a record review of Patient 15's ";Personal Information" indicated a Start of Care date of 3/22/23, with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a home visit on 7/7/23, at 11:44 a.m., it was observed Licensed Vocational Nurse (LVN 2) was providing care to Patient 15. Patient 15 was lying on a regular bed and mattress. There were no side rails on the bed. During a concurrent interview and record review on 7/7/23, at 11:44 a.m., Patient 15s record titled, ";Current Treatment/Medication/DME List" printed on 7/6/23, was reviewed with LVN 2. The record indicated Patient 15's physician ordered an air mattress and bed on 3/21/23. LVN 2 did not offer an explanation why Patient 15 did not have an air mattress and a medical bed as indicated in the record. During an interview on 7/7/23, at 3:40 p.m., the Director of Patient Care Services and Administrator (DPCS/ADM) stated she was not actively involved in the plan of correction and was ";just observing" the process. During an interview on 7/7/23, at 3:51 p.m., DPCS/ADM stated there was no evidence of the logs or audits done to correct the deficient practices. During an interview on 7/7/23, at 4:34 p.m., the Director of Patient Care Services Designee (DD) stated she did not know what happened to Patient 15s air mattress and medical bed. DD did not offer further explanation on why Patient 15 was missing the medical equipment as indicated in the plan of care. During a concurrent interview and record review on 7/7/23, at 4:52 p.m., of Patient 15's ";POC Summary" dated 7/6/23, was reviewed with the Director of Patient Care Services Designee (DD). The record indicated a registered nurse was supposed to see the patient every 14 days for an ongoing comprehensive assessment. The DD stated the nurse was supposed to see the patient on 6/28/23. There was no visit made. DD stated she did not know what happened. A record review of Patient 16's ";Personal Information" indicated a Start of Care date of 5/1/2023 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). A record review of Patient 16s form titled ";Plan of Care (POC)" dated 7/7/2023, indicated there was no documentation for the following sections: -No diet -No functional limitation -No allergies -No DME During a concurrent interview and record review on 7/7/2023, at 4:31 p.m., with DD, DD stated there should be documentation on the missing elements to make sure the family and staff knows the patients POC. A review of the HAs undated Plan of Correction (a document explaining how the agency will correct the deficient practice), indicated the agency updated all home charts with current medications and updated care plans tailored to individualized need of the patient and family. The record also indicated the Director of Patient Care Services was ultimately responsible for all corrective actions and ongoing compliance.

Based on observation and interview the Hospice Agency (HA) failed to ensure one of nine sampled patients (Patient 16) care giver was provided an ongoing information of the patients plan of care (POC) and their medication regimen. This failure had the potential to result in patients and their care givers lack of knowledge of the patient's POC or current medication regimen, which could lead to provision of poor care and services including medication errors. --- Findings: A record review of Patient 16's ";Personal Information" indicated a Start of Care date of 5/1/2023 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a record review on 7/6/2023, at 2:30 pm., of Patient 16s medication list provided by the Intake Coordinator (IC), the medication list indicated there were orders dated from 2020 to 2023. During a joint home visit on 7/6/2023 at 2:50 p.m., with License Vocational Nurse 2 (LVN2) of P16s residence, LVN2 reconciled Patient 16s medications from an old medication list in the HAs folder. LVN2 attempted to open the agencys Electronic Medical Record but was unable to. LVN2 stated that the medication list should be reconciled every visit and check for discontinued medication or any changes. LVN2 also stated Patient 16s Plan of Care was dated/printed on 7/6/2023. LVN2 stated ";A copy needs to be at home to see any changes, check her diagnosis, her DMEs. Also, to know what treatments she is ordered and the frequency of her visits. We have to follow the POC, if its not followed, we can miss patient treatments." During an interview on 7/7/23, at 3:40 p.m., the Director of Patient Care Services and Administrator (DPCS/ADM) stated she was not actively involved in the plan of correction and was ";just observing" the process. During an interview on 7/7/23, at 3:51 p.m., DPCS/ADM stated there was no evidence of the logs or audits done to correct the deficient practices. A review of the HAs undated Plan of Correction (a document explaining how the agency will correct the deficient practice), did not indicate a corrective action for this deficiency.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Medical Director was met as evidenced by: 1. The Hospice failed to ensure the medical director or physician designee reviews the clinical information for each hospice patient and provides written certification that it is anticipated that the patient's life expectancy is 6 months or less if the illness runs its normal course. The physician must consider the following when making this determination: (1) The primary terminal condition; (2) Related diagnosis(es), if any; (3) Current subjective and objective medical findings; (4) Current medication and treatment orders; and (5) Information about the medical management of any of the patient's conditions unrelated to the terminal illness for one sample patients (Patient 16) Refer to L667. 2. The Hospice failed to ensure before the recertification period for each patient, as described in §418.21(a), the medical director or physician designee must review the patient's clinical information for continued hospice care and services for three of nine sample patients (Patient 1, Patient 9 and Patient 11). Refer to L 668. The cumulative effect of this systemic practice resulted in the failure of the Hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to patients certified to receive hospice benefits. --- .

Based on interview and record review, the Hospice Agency (HA) failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for certification for one of nine sample patients (Patient 16) to support diagnosis of the patient's terminal illnesses and to be certified for hospice care services. This deficient practice resulted in the Hospice medical director and/or the hospice attending physicians certified the patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses and could result to lack and inappropriate care provided to the patients. --- Findings: During a record review of Patient 16's ";Personal Information" indicated a Start of Care date of 5/1/2023 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a record review on 7/6/2023, at 1:50 p.m., of Patient 16s Electronic Medical Record (EMR), the EMR indicated the Certification of Terminal Illness dated 5/1/2023 to 7/29/2023 did not have a certifying physician summary or was signed by the Medical Director 1 (MD1). During an interview on 7/7/23, at 3:57 p.m., the Director of Patient Care Services and Administrator (DPCS/ADM) stated the doctor needed to recertify patients for hospice care every 3 months. The DPCS/ADM stated it was the doctors responsibility to document the narrative in the certification of terminal illness to qualify the patient for hospice care. If the doctor does not document the reason patients are in hospice care, the agency will not know if the patient is eligible for care. If there is no certification, the agency does not have a right to continue admission to hospice care. During an interview on 7/7/23, at 3:40 p.m., the Director of Patient Care Services and Administrator (DPCS/ADM) stated she was not actively involved in the plan of correction and was ";just observing" the process. During an interview on 7/7/23 at 3:51 p.m., DPCS/ADM stated there was no evidence of the logs or audits done to correct the deficient practices. During an interview on 7/7/2023 at 3:57 p.m. with the Director of Patient Care Services/Administrator (DPCS/ADM), DPCS/ADM stated that the CTI needs to be completed by the physician every three months, 2-3 days before the recertification period. DPCS/ADM stated that the physician should document any patient or medication changes. DPCS/ADM stated ";Face to Face should be completed every month, thats how we do the IDG meetings. The physician should document any condition changes." DPCS/ADM stated that if not assessed the patients could not be receiving the right care. A review of the HAs undated Plan of Correction (a document explaining how the agency will correct the deficient practice), indicated the quality assurance coordinator and the nursing supervisor would review each patient chart for recertification assessments moving forward. Any deficiencies would be addressed in a timely manner. The record also indicated the Director of Patient Care Services was ultimately responsible for all corrective actions and ongoing compliance.

Based on interview and record review the Hospice medical director failed to ensure before recertifying the patients there must be a review of the clinical patients' information for continued hospice care and services to three of nine sample patients (Patient 1, Patient 9, and Patient 11). This deficient practice resulted in the Hospice medical director and/or the hospice attending physicians to re-certify the patients for continued hospice care without documented evidence of patients' clinical information to support the terminal illness diagnoses and could affect the patient's quality of care and quality of life. --- A record review of Patient 1 (P1) ";Personal Information" indicated a Start of Care date of 9/2/2021 with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure, which increases the workload on the heart inducing structural and functional changes.) During a record review on 7/6/2023 at 12:29 p.m. of P1s Electronic Medical Record (EMR), the EMR indicated P1s Certification of Terminal Illness dated 6/24/2023 to 8/22/2023 did not have a certifying physician summary or was signed by the Medical Director 1 (MD1). A record review of Patient 9 (P9) ";Personal Information" indicated a Start of Care date of 7/7/2022 with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). A review of P9s record titled, ";Physicians Certification for Hospice Benefit", for certification period 7/2/23 to 8/30/23, did not indicate a doctor had documented the reasons why P9 should continue hospice care. The document was not signed by a doctor. There was no narrative. The HA continued to provide hospice services without the doctor certifying P9 for hospice care. A record review of Patient 11 (P11) ";Personal Information" indicated a Start of Care date of 5/5/2022 with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). A review of P11s record titled, ";Physicians Certification for Hospice Benefit", for certification period 6/29/23 to 8/27/23, did not indicate a doctor had documented the reasons why P11 should continue hospice care. The document was not signed by a doctor. There was no narrative. The HA continued to provide hospice services without the doctor certifying P11 for hospice care. During an interview on 7/7/23, at 3:55 p.m., the Director of Patient Care Services and Administrator (DPCS/ADM) stated the doctor needed to recertify patients for hospice care every 3 months. The DPCS/ADM stated it was the doctors responsibility to document the narrative in the certification of terminal illness to qualify the patient for hospice care. If the doctor does not document the reason patients are in hospice care, the agency will not know if the patient is eligible for care. If there is no certification, the agency does not have a right to continue admission to hospice care. A review of the HAs undated Plan of Correction (a document explaining how the agency will correct the deficient practice), indicated a use of an admission checklist to ensure the following were present in the patients record: · A written or verbal orders for the referral to hospice, evidence of consultation prior to initiation of services. · A History and Physical or any pertinent information to support hospice criteria from the referring source. · No certification of Terminal Illness must be signed or approved for hospice service without supporting documents. · Modification of informed consent for hospice admission to include voice recording of the entire explanation of hospice service and benefits. The record also indicated the Director of Nurses would perform weekly review of all charts to ensure hospice criteria was met. The record further indicated the Director of Patient Care Services was ultimately responsible for all corrective actions and ongoing compliance.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Clinical Record was met as evidenced by: 1. The HA failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for three of nine sampled patients (Patient 1, Patient 11, and Patient 15). (Refer to L679). 2. The HA failed to ensure contents and information in the patients clinical records are safeguarded from unauthorized access by hospice and contracted staffs from making any alterations or modifications of the patient's clinical records for three of nine sampled patients (Patient 11, Patient 15, and Patient 16). (Refer to L680). The cumulative effect of these systemic practices resulted in the failure of the Hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients clinical records are safeguarded from unauthorized access by any individuals or hospice staff. --- .

Based on interview and record review the Hospice Agency (HA) failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for three of nine sampled patients (Patient 1, Patient 11, and Patient 15). This failure resulted in an unauthorized and inaccurate patient information or assessment entered in the patients clinical record that could affect the patients quality of care and well-being. --- Findings: During a record review of Patient 1's ";Personal Information" indicated a Start of Care date of 9/2/2021 with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure, which increases the workload on the heart inducing structural and functional changes.) During a record review on 7/6/2023, at 12:29 p.m., of Patient 1s Electronic Medical Record (EMR), the EMR indicated the patient's Certification of Terminal Illness (CTI) dated 6/24/2023 to 8/22/2023 did not have a certifying physician summary or the certification was signed by the Medical Director 1 (MD1). A copy of Patient 1s CTI dated 6/24/2023 to 8/22/2023, was requested from Owner (OW) on 7/6/2023 at 1 p.m. During a record review on 7/6/2023, at 1:22 p.m., of Patient 1s CTI dated 6/24/2023 to 8/22/2023, indicated CTI was signed and it had documentation under the certifying physician narrative. A review of the ";Audit Log" dated 7/5/2023 to 7/6/2023, indicated the log was printed for Patient 1, which included ";all staff" and under module ";Certification MD" indicated the following: Modification Date: 7/6/2023 1:17:11 PM; Staff: Medical Doctor 1; Module: Certification MD; Visit Date: 6/24/2023; Field/Section: Signed; Current Value: reviewed and electronically signed by (MD1); Previous Value: Signature/Signature on file; Module ID:1466242; IP Address: 159 250 185. 182. A record review of Patient 11's ";Personal Information" indicated a Start of Care date of 5/5/2022 with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). During an interview on 7/7/23, at 4:34 p.m., the Director of Patient Care Services Designee (DD) stated the IDG members were expected to sign the ";POC/IDG review" document on the date of the IDG meeting, to validate their attendance and input during the meeting. The DD stated the MSW and CP members were expected to document their own input in the form. During an interview on 7/7/23, at 4:40 p.m., the DPCS/ADM stated she documented on Patient 11s records because it needed to be completed. The DPCS/ADM stated she did not attend the meeting on 6/29/23 because she was sick but documented on the records because she had the information. During an interview on 7/7/23, at 4:44 p.m., the DPCS/ADM stated PE 2 was making edits in the medical record of Patient 11 because she was probably completing documentation. A record review of Patient 11s audit log (a document that records the date, time, and persons making additions, changes, and/or edits in a medical record), dated 7/5/23 to 7/7/23, indicated the following: · Record titled ";POC/IDG review" dated 6/29/23, was signed by the DPCS/ADM on 7/6/23. · The DPCS/ADM entered notes for the Medical Social Worker (MSW) and Chaplain (CP) in record titled, ";POC/IDG review", dated 6/29/23, on 7/5/23. Previously, nothing was documented. · The DPCS/ADM edited notes for ";summary discussion" for IDG meeting dated 6/29/23, on 7/6/23. · Previous Employee 2 (PE 2) changed notes for ";summary discussion" for IDG meeting dated 6/1/23, on 7/5/23. A record review of Patient 11s record titled ";POC/IDG review" dated 6/29/23, indicated: · The DPCS/ADM documented an inaccurate date the document was signed. · The MSW and CP signed the document, despite not being the author of the notes entered under the section titled, ";Spiritual" and ";Psychosocial". · The DPCS/ADM edited notes for 6/29/23, despite not being present in the meeting. · The record falsely identified the DPCS/ADM as the author of the ";Nursing IDG Discussion". The author of the note was PE 2. A record review of Patient 15's ";Personal Information" indicated a Start of Care date of 3/22/23, with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). During an interview on 7/7/23, at 4:40 p.m., the DPCS/ADM stated she documented on Patient 15s records because it needed to be completed. The DPCS/ADM stated she did not attend the meeting on 6/29/23 because she was sick but documented on the records because she had the information. During an interview on 7/7/23, at 4:44 p.m., the DPCS/ADM stated PE 2 was making edits in the medical record of Patient 15 because she was probably completing documentation. A record review of Patient 15s audit log dated 7/5/23 to 7/7/23, indicated the following: · Record titled ";POC/IDG review" dated 6/29/23 was signed by the DPCS/ADM on 7/6/23. · The DPCS/ADM entered notes for the MSW and CP in record titled, ";POC/IDG review", dated 6/29/23, on 7/5/23. Previously, nothing was documented. · PE 2, edited document titled ";POC/IDG review", dated 6/1/23, on 7/5/23. A record review of Patient 15s record titled ";POC/IDG review", dated 6/29/23, indicated: · The DPCS/ADM documented an inaccurate date the document was signed. · The MSW and CP signed the document, despite not being the author of the notes entered under the section titled, ";Spiritual" and ";Psychosocial". · The DPCS/ADM signed for 6/29/23, despite not being present in the meeting. · The record falsely identified the DPCS/ADM as the author of the ";Nursing IDG Discussion". The author of the note was PE 2. A review of the HAs undated Plan of Correction (a document explaining how the agency will correct the deficient practice), indicated all staff had to understand the need and responsibility to maintain a high level of security with computer access. The record further indicated the administrator was ultimately responsible for all corrective actions and ongoing compliance.

Based on interview and record review the Hospice Agency (HA) failed to ensure contents and information in the patients clinical record records are safeguarded from unauthorized access by hospice and contracted staffs from making any alterations or modifications for three of nine sampled patients (Patient 11, Patient 15, and Patient 16). This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients' clinical records that could affect the patients quality of care and well-being. --- Findings: a. A record review of Patient 11's ";Personal Information" indicated a Start of Care date of 5/5/2022 with a primary diagnosis of Alzheimers Disease (generalized degeneration of the brain). A record review of Patient 11s audit log (a document that records the date, time, and persons making additions, changes, and/or edits in a medical record), dated 7/5/23 to 7/7/23, indicated the following: · Previous Employee 2 (PE 2) changed notes for ";summary discussion" for IDG meeting dated 6/1/23, on 7/5/23. A record review of Patient 11s record titled ";POC/IDG review", dated 6/29/23, indicated: · The record falsely identified the Director of Patient Care Services and Administrator (DPCS/ADM) as the author of the ";Nursing IDG Discussion". The author of the note was PE 2. b. A record review of Patient 15's ";Personal Information" indicated a Start of Care date of 3/22/23, with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). A record review of Patient 15s audit log dated 7/5/23 to 7/7/23, indicated the following: · PE 2 edited a document titled ";POC/IDG review" dated 6/1/23, on 7/5/23. A record review of Patient 15s record titled ";POC/IDG review" dated 6/29/23, indicated: · The record falsely identified the DPCS/ADM as the author of the ";Nursing IDG Discussion". The author of the note was PE 2. c. A record review of Patient 16's ";Personal Information" indicated a Start of Care date of 5/1/2023 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a record review on 7/7/2023, at 11:48 a.m., of Patient 16s Electronic Medical Record (EMR), the EMR indicated the Intake Coordinator (IC) entered Medical Director 1 (MD1) orders for the patient. During an interview on 7/7/2023, at 4:58 p.m., with the DPCS/ADM, the DPCS/ADM stated that registered nurses or license vocational nurses are the only people allowed to take and receive physician orders. During a concurrent interview and record review on 7/7/2023, at 5:09 p.m., with the DPCS/ADM of Patient 16s EMR, the DPCS/ADM stated that the ADM has the ";highest" level of access in the EMR (Electronic Medical Record). DPCS/ADM also stated that she did not know who gave the IC, ADM access. During an interview on 7/7/23, at 3:37 p.m., the DPCS/ADM stated PE 2 resigned on 6/22/23. During an interview on 7/7/23, at 4:44 p.m., the DPCS/ADM stated PE 2 was making edits in the clinical records of both Patient 11 and Patient 15 because she was probably completing documentation. During an interview on 7/7/23, at 5:05 p.m., the Director of Patient Care Services Designee (DD) stated she did not know who was responsible in giving access to the electronic medical records. A review of the HAs undated Plan of Correction (a document explaining how the agency will correct the deficient practice), indicated all staff had to understand the need and responsibility to maintain a high level of security with computer access. The record further indicated the administrator was ultimately responsible for all corrective actions and ongoing compliance. A review of the HAs undated Plan of Correction (a document explaining how the agency will correct the deficient practice), indicated all staff had to understand the need and responsibility to maintain a high level of security with computer access. The record further indicated the administrator was ultimately responsible for all corrective actions and ongoing compliance.

Based on interview and record review, the Hospice Agency (HA) failed to ensure one of 14 sampled patients (Patient 8) received Patient Rights information in Spanish, a language the patient understands. This failure had the potential to result in the patient not being aware of his rights and responsibilities he has while receiving hospice services. --- A record review of Patient 8 (P8) ";Personal Information" indicated a Start of Care date of 4/12/2023 with a primary diagnosis of chronic ischemic heart disease (heart weakening caused by reduce blood flow to the heart). During an interview during the home visit on 5/17/23, at 2:00 p.m., P8 stated he did not know what hospice care meant. During a concurrent interview and record review on 5/17/23, at 2:10 p.m. P8s folder was reviewed. The folder indicated documents titled, ";Patients Rights" and agency information pamphlets. The record further indicated all literature provided to P8 was in English. P8 stated he does not read English. P8 stated preferred language is Spanish. P8 stated he can read Spanish. During a concurrent interview and record review on 5/17/23, at 2:15 p.m. P8s folder was reviewed with Licensed Vocational Nurse 1 (LVN1). LVN 1 stated all the information in the folder was in English. LVN 1 stated P8 should have it in preferred language, in his case Spanish, because P8 needed to understand the information and it is his right. A review of facilitys policy and procedure titled, ";Rights/Responsibilities" revised April 2017, indicated ";To encourage awareness of patient rights and responsibilities, to provide guidelines to assess patients making decisions regarding care and to support active participation in care planning. 1. R. The right to have communication needs met. T. The right to have cultural, psychosocial, spiritual/religious, and personal values, beliefs, and preferences respected. 4. The Patient Rights and Responsibilities statement will be explained and distributed to the patient prior to the initiation of organization services. This explanation will be in a language or communication method that the patient can reasonably be expected to understand."

Based on observation, interview and record review, the hospice agency failed to ensure the Conditions of Participations regarding initial and Comprehensive Assessments of Patients was met as followed: 1. The hospice agency staff failed to conduct and document comprehensive assessment identifying the need for hospice care and services for four of 14 sample selected patients (Patient 3, Patient 5, Patient 7, and Patient 8). These patients did not have life expectancy of six months or less, and had no documented need for physical, psychosocial, emotional, or spiritual care. The agency failed to assess and document how many patients met the admission criteria for the Medicare hospice benefit. (Refer to L 522). 2. The hospice agency failed to ensure the interdisciplinary group complete the comprehensive assessment no later than 5 calendar days after election for three of 14 sampled patients (Patient 1, Patient 2, and Patient 5). (Refer to L 523). 3. The hospice agency failed to ensure the comprehensive assessment identified the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that addressed the hospice patient's well-being, comfort, and dignity throughout the dying process for two of 14 patients (Patient 7 and Patient 8). (Refer to L 524). 4. The hospice staff failed to review all medications the patients were taking and update the medication profiles with the currently used medications for one of 14 sample selected patients (Patient 5). The patients were at risk for medication errors and adverse drug reactions. (Refer to L 530). 5. The hospice agency failed to ensure an initial bereavement assessment was done for three of 14 sample selected patients (Patient 5, Patient 6, and Patient 7), which focused on the social, spiritual, and cultural factors that may affect the ability of the family and other individuals involved in the care, to cope with the patients death. (Refer to L 531). 6. The hospice agency failed to ensure the interdisciplinary group (IDG) met and updated the comprehensive assessment at least every 15 days for four out of 14 sample selected patients (Patient 1, patient 2, Patient 3, and Patient 5). (Refer to L 533). The cumulative effect of these systemic practices resulted in the hospice agency admitting patients who did not meet admission criteria and did not qualify for the Medicare hospice benefit. --- -

Based on interview and record, the Hospice Agency (HA) staff failed to conduct and accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for four of 14 sample selected patients (Patient 3, Patient 5, Patient 7, and Patient 8). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- a.) A record review of Patient 3 (P3) ";Personal Information" indicated a Start of Care date of 11/23/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). A record review of P3s History and Physician (H&P) from her Medical Center dated 11/22/2022, did not indicate or mentioned P3s weight or weight loss. A record review of P3s ";Comprehensive Nursing Assessment" visit date 11/23/2022, indicated P3s MAC (Mid Arm Circumference – measure that can be used to determine lean body mass and fat reserves) was 38 on right arm. It also stated under the Narrative section, ";Patient has positive weight loss during the last 6 months... Patient is eligible for hospice services and meets LCD (Local Coverage Determination - LCD describes guidelines to be used by hospice providers to determine eligibility of beneficiaries for hospice benefits) guidelines." During a telephone interview on 5/18/2023 at 12:15 p.m. with MD1, MD1 stated that he reviews patients referral and medical history to see if ";they have a diagnosis consistent with hospice." MD1 also stated, ";I use the nursing assessment as part of, a lot of it is the important information to fill out as hospice." During a concurrent interview and record review on 5/19/2023 at 12:50 p.m. with the Director of Patient Care Services Designee (DD) of P3s Electronic Medical Record (EMR) document LCD, DD stated, ";I cant find that it says weight loss on her H&P." DD was asked if P3 had any weight loss since being admitted to the HA. DD stated, ";I dont see anything different. The MAC auto populates." A record review of P3s ";POC (plan of care)/IDG (Interdisciplinary group) Review" dated 5/4/2023, did not indicate P3s weight or weight loss was mentioned. A record review of P3s medical record document titled ";Visit Note LVN" dated 5/12/2023, 5/5/2023, 4/28/2023, 4/21/2023, and 4/14/2023 indicated, P3s MAC is 38. b.) A record review of Patient 5 (P5) ";Personal Information" indicated a Start of Care date of 2/27/2023 with a primary diagnosis of secondary malignant neoplasm of unspecified site (cancer of the unknown). A record review of P5s Electronic Medical Record (EMR), the EMR did not indicate P5s cancer site. A record review of P5s CTI (Certification of Terminal Illness) for certification period 2/27/2023 t o5/27/2023, provided by the Intake Coordinator (IC) on 5/18/2023, indicated MD2s name and electronic signature were on the CTI form. Section ";Certifying Physician Summary" did not contain written certification that the patient's life expectancy is 6 months or less if the illness runs its normal course. The CTI form indicated, ";Life expectancy short, prognosis is poor." Lastly, MD2 wrote ";Ms. ... with stage 4 cancer and metastatic disease." Site of cancer was not documented on the CTI. During a joint home visit on 5/17/2023 at 10 a.m. with License Vocational Nurse (LVN) to P5s home, P5 stated in Spanish that she had lung cancer. During a concurrent interview and record review on 5/19/2023, at 11:50 a.m. with the Director of Patient Care Services Designee (DD) of P5s EMR, the EMR indicated there was no mention of P5 s cancer site was documented. DD stated, ";Personally, I know is a breast cancer. I cannot find it in the initial assessment." DD stated, ";Comprehensive assessment is a full head to toe assessment, it does not have all the patient information. We are taking care of the patient we need to know what diagnosis is. We went by her code that came from the hospital. The CTI does not mention anything as well." c). A record review of Patient 7 (P7) ";Personal Information" indicated a Start of Care date of 12/1/2022 and a discharge date of 12/7/22 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). A record review of P7s record titled, ";Audit log" (a document that indicates the details of the changes made to a record), dated 12/1/2022 to 5/19/2023, indicated ";Modified Date 5/17/2023 3:54:02 PM, Staff: License Vocational Nurse 2 (LVN2), Module: Visit Note, Visit Date: 12/3/2022, Field/Section: Created, Current Value and Previous value are both blank, Module ID: 9934920." Further review of log, log indicated that LVN2 completed part of the document and Registered Nurse 1 (RN1) completed the rest 5/17/2023 6:22:33 PM. 1a). A record review of Patient 8 (P8) ";Personal Information" indicated a Start of Care date of 4/12/2023 with a primary diagnosis of chronic ischemic heart disease (heart weakening caused by reduce blood flow to the heart). d). During a home visit on 5/17/23, at 1:55 p.m., P8s care was observed. P8 was lying in bed, and independently sat up to the side of the bed when licensed vocational nurse 1 (LVN 1) walked in. P8 was observed breathing normally, without any signs of distress. During an interview during the home visit on 5/17/23, at 2:00 p.m., P8 stated he went to the dentist earlier, using a taxi because the person who normally drives him to doctors appointment was involved in an accident. P8 stated he went to the dentist by himself. P8 stated he had a primary care physician and stated the doctor said his condition was fine, he was doing well. P8 stated he has been on dialysis for 4 years. When asked if patient knew what hospice care is, he stated he did not know what hospice care meant. During the interview, P8 showed this surveyor a dialysis access port on his left upper arm. During an interview during the home visit on 5/17/23, at 2:20 p.m., P8 stated he uses a cane to go walk outside. P8 stated he enjoys walking outdoors, in the sidewalk of the streets. P8 stated he walks to ";San Fernando" street. During a concurrent interview and record review on 5/25/23, at 11:53 a.m., P8s electronic medical record (EMR) was reviewed with the Director of Patient Care Services Designee (DD). The DD stated the comprehensive nursing assessment did not indicate P8 was on Dialysis, and it should be included. The DD stated the comprehensive nursing assessment was incomplete. The DD stated the HA need to maintain proper skin care and assess his dialysis access. The DD stated there is no mention of his dialysis in the IDG meetings either. A record review of P8s clinical record titled, ";Comprehensive Nursing Assessment", dated 4/12/2023, indicated, ";Wt (lbs) 177, BMI 31.4. The record further indicated ";KPS 50 (requires considerable assistance with activities of daily living), PPS 50 (mainly sit/lie, activity level is cannot do any work, self-care considerable assistance needed) ...". d1). During an interview during the home visit on 5/17/23, at 2:00 p.m., P8 stated he did not know what hospice care meant. During an interview on 5/19/23, at 9:25 a.m., P8s authorized representative (AR) stated she was not related to P8. The AR stated her relationship to P8 was as a caregiver until November 2022. During an interview on 5/19/23, at 9:31 a.m., the Home Health Case Manager (HHCM), stated P8 was discharged from the Home Health Agency (HHA) on April 2023 because P8s family requested hospice care. The HHCM stated the HHA referred the patient to hospice care. The HHCM provided the contact information of P8s family. The name and phone number provided were identical as the information in P8s record titled, ";Personal Information", under section ";Authorized Rep (AR), Phone and Personal Information Cell". During a concurrent interview and record review on 5/19/23 at 11:13 a.m., P8s undated record titled, ";Personal Information" was reviewed with the Director of Patient Care Services Designee (DD). The record indicated, ";Authorized Rep (representative)/Emergency Contact (EC)". Further review of the record indicated section ";Personal Information Cell" and ";Phone" of the PCG were the same. The DD stated the AR was P8s primary contact, his daughter. During a concurrent interview and record review on 5/19/23 at 11:15 a.m., P8s record titled, ";Physician Order", dated 4/12/23, was reviewed with the DD. The record indicated, ";Orders Received a call from patients family who report the patient will be starting hospice care." When asked to provide an explanation of the record, the DD called P8s nurse to inquire about information regarding P8s primary care giver. The DD stated P8 had a daughter but was not involved in P8s care. The name of P8s daughter was not provided. The DD stated she did not know who entered the information in P8s record and would follow up with the intake coordinator (IC). A record review of P8s clinical record titled, ";Comprehensive Nursing Assessment", dated 4/12/2023, indicated, ";Narrative & Disease Trajectory...Hospice philosophy and services explained to patient family...Patients family requested to have a DNR (do not resuscitate) code...Consents for Hospice services signed by patients daughter AR..." A review of facilitys policy and procedure titled, ";Initial Assessment" revised April 2017, indicated ";An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care... To provide guidelines for the initial assessment to evaluate the patients physical, psychosocial, and emotional needs and determine immediate care and support needs." A review of facilitys policy and procedure titled, ";The Plan of Care" revised April 2017, indicated ";The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days... This plan must be initiated at start of care...4. The plan of care... must state, in detail, the scope and frequency of services needed... 5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care." A review of facilitys policy and procedure titled, ";Admission Criteria and Process" revised April 2017, indicated ";17. If the patient is accepted for hospice care, a comprehensive assessment of the patient will be performed no later than five (5) calendar days..." A review of facilitys policy and procedure titled, ";Medical Record Content" revised April 2017, indicated ";The Agency will initiate and maintained and individual and accurate medical record for each patient receiving care... Each medical record will contain the following: -Patient history relevant to admission. -A current medication profile... -Primary and secondary diagnosis related to the patient care as assessed upon admission and updated during the course of care." A review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised April 2017, indicated ";1. During the comprehensive assessment patient assessment, all baseline data and other relevant information will be documented in the patients clinical record...1. G. Physical assessment, including...relevant data related to pertinent physical findings and the patients terminal illness. 1. K. Patients past and present medical history..."

Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient.) complete the comprehensive assessment no later than 5 calendar days after election for three of 14 sampled patients (Patient 1, Patient 2, and Patient 5). This failure had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- a.) A record review of Patient 1 (P1) ";Personal Information" indicated a Start of Care date of 9/2/2021 with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure, which increases the workload on the heart inducing structural and functional changes.) A record review of P1s Electronic Medical Record (EMR) document titled ";POC (Plan of Care- an individualized care planned for patient) /IDG Review" dated 9/2/2021, indicated there were no signatures in sections ";MD signature, MSW signature, and Chaplain signature." A record review of P1s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 9/15/2021, indicated there were no signatures in sections ";MD signature, MSW signature, and Chaplain signature." A record review of P1s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 9/29/2021, indicated there were no signatures in sections ";MD signature, MSW signature, and Chaplain signature." b.) A record review of Patient 2 (P2) ";Personal Information" indicated a Start of Care date of 4/14/2023 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). A record review of P2s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 4/14/2023, indicated there were no signatures in sections ";MSW signature, and Chaplain signature." A record review of P2s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 4/20/2023, indicated there were no signatures in sections ";MSW signature, and Chaplain signature." A record review of P2s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 5/4/2023, indicated there were no signatures in sections ";MSW signature, and Chaplain signature." c.) A record review of Patient 5 (P5) ";Personal Information" indicated a Start of Care date of 2/27/2023 with a primary diagnosis of secondary malignant neoplasm of unspecified site (cancer of the unknown). A record review of P5s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 2/27/2023, indicated there were no signatures in sections ";RN signature, MSW signature, and Chaplain signature." A record review of P5s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 3/9/2023, indicated there were no signatures in sections ";MSW signature, and Chaplain signature." A record review of P5s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 3/23/2023, indicated there were no signatures in sections ";MSW signature, and Chaplain signature." A record review of P5s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 4/6/2023, indicated there were no signatures in sections ";MD signature, MSW signature, and Chaplain signature." During a telephone interview on 5/18/2023 at 12:15 p.m. with the Medical Director 1 (MD1), MD1 stated, ";The IDGs are every two weeks, the next is supposed to be today. Usually is in person, this week I couldnt make it but this week... There is a sign in sheet that I sign." During an interview on 5/19/2023 at 10:33 a.m. with the Director of Patient Care Services (DPCS) the DPCS stated, ";We do initial meeting to begin the POC, then every 2 weeks." DPCS was unable to provide the sign in sheet. DPCS stated, ";There is no sign in sheet, we sign in (EMR)". A review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised April 2017, indicated ";5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days. B. If no changes are needed, then that must be documented." A review of facilitys policy and procedure titled, ";Ongoing Comprehensive Assessment" revised April 2017, indicated ";3. Ongoing comprehensive assessment should focus on: D. Changes in patients care environment or support systems. 4. Based on the assessments, the plan of care – including problems, needs, goals, and outcomes – will be reviewed and updated by the interdisciplinary group members responsible for the case." A review of facilitys policy and procedure titled, ";Physician Services-Medical Director" revised April 2017, indicated ";The duties and responsibilities of the Medical Director will include... 3. Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with... interdisciplinary group... including written certification of terminal illness. 6. Reviewing and updating the plan of care every 15 days, or more frequently as needed in conjunction with the attending physician and interdisciplinary group." A review of facilitys policy and procedure titled, ";The Plan of Care" revised April 2017, indicated ";The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days... This plan must be initiated at start of care...5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care." A review of facilitys policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" revised April 2017, indicated ";The hospice interdisciplinary team/group members will include, at a minimum: A. Physician. B. Registered Nurse. C. Social Worker. D. Pastoral or other counselor. The interdisciplinary group will: A. Participate in the establishment of the plan of care for each patient admitted... B. Participate in the periodic review and updating of the plan of care for each patient..." A review of facilitys policy and procedure titled, ";Medical Record Content" revised April 2017, indicated ";The Agency will initiate and maintained and individual and accurate medical record for each patient receiving care... Each medical record will contain the following: -Primary and secondary diagnosis related to the patient care as assessed upon admission and updated during the course of care."

Based on interview and record review the Hospice Agency (HA) failed to ensure the comprehensive assessment identified the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that addressed the hospice patient's well-being, comfort, and dignity throughout the dying process for two of 14 patients (Patient 7 and Patient 8). This failure had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- a). A record review of Patient 7 (P7) ";Personal Information" indicated a Start of Care date of 12/1/2022 and a discharge date of 12/7/22 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During an Electronic Record Review (EMR) of P7s medical record on 5/17/2023, indicated there was no history of an initial spiritual assessments documented. During a telephone interview on 5/19/2023 at 4:01 p.m. with the Chaplin (CP ), stated that he did not have anything pending, and that when and if the HA needs his services, they will call. CP stated that he conducts the patients initial bereavement assessment within five days of admission. CP stated, ";I put my documentation in (Electronic Medical Record - EMR). Normally if its initial within 5 days as soon as I have access to computer. Last time I documented in (EMR) was a few months ago. I have my own password and username. We are not supposed to share the username or password to share with anybody. Its my responsibility and the patients to do follow up." A record review of P7s record titled, ";Audit log" (a document that indicates the details of the changes made to a record), dated 12/1/2022 to 5/19/2023, indicated ";Modified Date: 5/17/23...Staff: Chaplain (CP), Module: Bereavement Assessment, Visit Date: 12/2/2022, Field/Section: Created, Current Value and Previous value are blank. b). A record review of Patient 8 (P8) ";Personal Information" indicated a Start of Care date of 4/12/2023 with a primary diagnosis of chronic ischemic heart disease (heart weakening caused by reduce blood flow to the heart). During a concurrent interview and record review on 5/19/23 at 11:02 a.m., P8s electronic medical record (EMR) was reviewed with the Director of Patient Care Services Designee (DPCSD). (DPCSD) stated Spiritual Counselor (SC) saw P8 on 4/14/23 for bereavement assessment, but the spiritual assessment was not done. The SC stated there was a note that the P8 declined SC services. The DPCSD stated, she did not know what happened. A record review of P8s clinical record titled, ";Comprehensive Nursing Assessment", dated 4/12/2023, indicated, ";Spiritual Screening: Patient is active in faith tradition: yes...Referrals: Spiritual Care...Narrative & Disease Trajectory...signs and symptoms of depression is also observed. Patient looks sad and has no interest to engage in any activities...". A review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised April 2017, indicated ";1. During the comprehensive assessment patient assessment, all baseline data and other relevant information will be documented in the patients clinical record...as relevant... R. The patients psychosocial status... T. An assessment of the patients and family/caregivers spiritual orientation... W. A bereavement assessment of the needs of the patients family..." A review of facilitys policy and procedure titled, ";Ongoing Comprehensive Assessment" revised April 2017, indicated ";2. The nurse will assess the patient on each visit, for: D. Current treatment related to the identified symptoms and the patients response. N. Spiritual issues. O. Additional psychosocial issues." A review of facilitys policy and procedure titled, ";The Plan of Care" revised April 2017, indicated ";The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days... This plan must be initiated at start of care... 12. The written plan of care will contain... B. Identification of patient and family/caregiver needs, including... psychosocial... spiritual..." A review of facilitys policy and procedure titled, ";Spiritual Assessment" revised April 2017, indicated ";2. The Hospice Chaplain will contact the patient/family by a home visit or by telephone based on the patients and familys needs and acceptance of these services. 3. If the patient and family/caregiver refuse these services, the refusal will be documented. The interdisciplinary group members will continue to assess for spiritual needs... 4. The in-depth spiritual assessment will be performed by the Hospice Chaplain..." A review of facilitys policy and procedure titled, ";Psychosocial Assessment" revised April 2017, indicated ";1. A social work contact will be made either by a home visit or by telephone based on the patients and familys needs and acceptance of these services. 2. A psychosocial assessment will be performed at the initial meting of patient and family/caregiver... 6. If the patient and/or family/caregiver refuses psychosocial visits, patient and family/caregiver needs will continue to be assessed on an ongoing basis."

Based on interview and record review, the Hospice Agency (HA) staff failed to review all medications the patients were taking and update the medication profiles with the currently used medications for one of 14 sampled patients (Patient 5). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. --- A record review of Patient 5 (P5) ";Personal Information" indicated a Start of Care date of 2/27/2023 with a primary diagnosis of secondary malignant neoplasm of unspecified site (cancer of the unknown). A record review of P5s ";Current Treatment/Medication/DME List" indicated P5 was prescribed ";Dilauded (pain medication) 1-2 mg (milligrams) tablets, one tablet orally every 3-4 hours as needed for severe pain..." on 4/15/2023. During a joint home visit on 5/17/2023 at 10 a.m. with License Vocational Nurse (LVN1) to P5s home, LVN1 was noted reviewing yellow colored ";Medication Supplies/Order Form" that was located inside P5s hospice folder. LVN1 stated, ";I dont know why there is no current list here. The only this missing is the Dilauded" A record review of P5s hospice folder indicated there was an undated ";Medication Supplies/Order Form" which indicated there was no order for Dilauded documented." The hospice folder also indicated there was no ";Current Treatment/Medication/DME List" for P5. A review of facilitys policy and procedure titled, ";Ongoing Comprehensive Assessment" revised April 2017, indicated ";2. The nurse will assess the patient on each visit, for: D. Current treatment related to the identified symptoms and the patients response." A review of facilitys policy and procedure titled, ";Physician Services-Medical Director" revised April 2017, indicated ";The duties and responsibilities of the Medical Director will include... 3. Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with... interdisciplinary group... including written certification of terminal illness." A review of facilitys policy and procedure titled, ";Medication Profile" revised April 2017, indicated ";Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medication." A review of facilitys policy and procedure titled, ";Medical Record Content" revised April 2017, indicated ";The Agency will initiate and maintained and individual and accurate medical record for each patient receiving care... Each medical record will contain the following: -A current medication profile..."

Based on interview and record review the facility failed to conduct or attempt to conduct a bereavement assessment to provide bereavement counseling in accordance with the patient/family's needs for three of 14 sample selected patients (Patient 5, Patient 6, and Patient 7). This deficient practice had the potential for the patient/family not being provided social, spiritual, and cultural support related to the patient's death. --- a.) A record review of Patient 5 (P5) ";Personal Information" indicated a Start of Care date of 2/27/2023 with a primary diagnosis of secondary malignant neoplasm of unspecified site (cancer of the unknown). A record review of P5s record titled, ";Audit log" (a document that indicates the details of the changes made to a record), dated 2/1/2022 to 5/19/2023, indicated ";Modified Date: 5/17/23...Staff: Chaplain (CP), Module: Bereavement Assessment, Visit Date: 2/27/2023, Field/Section: Created, Current Value and Previous value are blank. b.) A record review of Patient 6 (P6) ";Personal Information" indicated a Start of Care date of 12/3/2022 and a discharge date due to death of 12/6/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During an Electronic Record Review (EMR) of P6s medical record on 5/17/2023, indicated there was no initial bereavement assessment, bereavement plan of care, post death bereavement assessment, bereavement letters, or post death bereavement support documented. c.) A record review of Patient 7 (P7) ";Personal Information" indicated a Start of Care date of 12/1/2022 and a discharge date of 12/7/22 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During an Electronic Record Review (EMR) of P7s medical record on 5/17/2023, indicated there was no initial bereavement assessment, bereavement plan of care, post death bereavement assessment, bereavement letters, or post death bereavement support documented. During an interview on 5/19/2023 at 10:20 a.m. with the Director of Patient Care Services Designee (DPCSD), DPCSD stated that the Chaplain (CP), ";They do initial bereavement within five days; he needs to get to know the family. Assess the relatives of the patient how they will cope with the patient illness if they need any help to give them support." DPCSD also stated that the CP also is responsible for creating the bereavement plan and goals. During a telephone interview on 5/19/2023 at 3:23 p.m. with the CP, CP stated, ";In 5 days, I do my initial assessment and if there is a need to follow up then I follow up." During a telephone interview on 5/19/2023 at 4:01 p.m. with the CP, CP stated that he did not have anything pending, and that when and if the HA needs his services, they will call. CP stated that he conducts the patients initial bereavement assessment within five days of admission. CP stated, ";I put my documentation in (HAs Electronic Medical Record - EMR). Normally if its initial within 5 days as soon as I have access to computer. Last time I documented in (EMR) was a few months ago. I have my own password and username. We are not supposed to share the username or password to share with anybody. Its my responsibility and the patients to do follow up." A review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised April 2017, indicated ";1. During the comprehensive assessment patient assessment, all baseline data and other relevant information will be documented in the patients clinical record...as relevant... W. A bereavement assessment of the needs of the patients family..." A review of facilitys policy and procedure titled, ";Ongoing Comprehensive Assessment" revised April 2017, indicated ";2. The nurse will assess the patient on each visit, for: N. Spiritual issues. O. Additional psychosocial issues. 3. Ongoing comprehensive assessment should focus on: D. Changes in patients care environment or support systems." A review of facilitys policy and procedure titled, ";Physician Services-Medical Director" revised April 2017, indicated ";The duties and responsibilities of the Medical Director will include... 3. Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with... interdisciplinary group... including written certification of terminal illness. 6. Reviewing and updating the plan of care every 15 days, or more frequently as needed in conjunction with the attending physician and interdisciplinary group." A review of facilitys policy and procedure titled, ";Bereavement Assessment" revised April 2017, indicated ";(HA) will provide bereavement services for up to one year after the patients death to surviving family/caregiver members. 3. Bereavement needs will be reassessed during each contact. 4. After the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment. 5. The Bereavement Coordinator will develop a plan for intervention, based on the findings of the bereavement follow-up assessment and input from interdisciplinary group members." A review of facilitys policy and procedure titled, ";Bereavement services" revised April 2017, indicated ";(HA) will provide an organized bereavement program... The program will provide bereavement services to the family/caregiver or hospice patients, before and after the patients death, in accordance with the plan of care. 1. A bereavement risk assessment will be completed... at the time of admission... 2. After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented and updated as needed. A review of facilitys policy and procedure titled, ";Listing of Services Provided" revised April 2017, indicated ";2. Services will be provided as listed below: Directly –bereavement services...."

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met and updated the comprehensive assessment at least every 15 days for four out of 14 sample selected patients (Patient 1, patient 2, Patient 3, and Patient 5). This deficient practice had potential for harm if patients are prevented from reaching their goals, due to IDG not addressing changes in the patient's condition --- a.) A record review of Patient 1 (P1) ";Personal Information" indicated a Start of Care date of 9/2/2021 with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure, which increases the workload on the heart inducing structural and functional changes.) A record review of P1s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 5/4/2023, indicated there were no signatures in sections ";MD signature and Chaplain signature." A record review of P1s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 4/20/2023, indicated there were no signatures in sections ";MD signature and Chaplain signature." A record review of P1s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 4/6/2023, indicated there were no signatures in sections ";Chaplain signature." A record review of P1s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 3/3/2023, indicated there were no signatures in sections ";Chaplain signature." A record review of P1s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 3/9/2023, indicated there were no signatures in sections ";Chaplain signature." b.) A record review of Patient 2 (P2) ";Personal Information" indicated a Start of Care date of 4/14/2023 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). A record review of P2s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 4/14/2023, indicated there were no signatures in sections ";MSW signature, and Chaplain signature." A record review of P2s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 4/20/2023, indicated there were no signatures in sections ";MSW signature, and Chaplain signature." A record review of P2s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 5/4/2023, indicated there were no signatures in sections ";MSW signature, and Chaplain signature." c.) A record review of Patient 3 (P3) ";Personal Information" indicated a Start of Care date of 11/23/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). A record review of P3s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 4/14/2023, indicated there were no signatures in sections ";MD signature, and Chaplain signature." A record review of P3s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 4/20/2023, indicated there were no signatures in sections ";MD signature, and Chaplain signature." A record review of P3s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 4/6/2023, indicated there were no signatures in sections ";MD signature, and Chaplain signature." A record review of P3s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 3/23/2023, indicated there were no signatures in sections ";MD signature, and Chaplain signature." A record review of P3s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 3/9/2023, indicated there were no signatures in sections ";MD signature, and Chaplain signature." d.) A record review of Patient 5 (P5) ";Personal Information" indicated a Start of Care date of 2/27/2023 with a primary diagnosis of secondary malignant neoplasm of unspecified site (cancer of the unknown). A record review of P5s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 2/27/2023, indicated there were no signatures in sections ";RN signature, MSW signature, and Chaplain signature." A record review of P5s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 3/9/2023, indicated there were no signatures in sections ";MSW signature, and Chaplain signature." A record review of P5s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 3/23/2023, indicated there were no signatures in sections ";MSW signature, and Chaplain signature." A record review of P5s Electronic Medical Record (EMR) document titled ";POC/IDG Review" dated 4/6/2023, indicated there were no signatures in sections ";MD signature, MSW signature, and Chaplain signature." During a telephone interview on 5/18/2023 at 12:15 p.m. with the Medical Director 1 (MD1), the MD1 stated, ";The IDGs are every two weeks... Basically, there is a panel of patients. We start at the beginning we get the RN (registered nurse) report I thoroughly listen and see what is needed for the patient; orders or in services and what not. If they need orders, I provide new orders. We go one by one..." MD1 stated the IDG members consisted of the Director of Patient Care Services Designee (DPCSD), and Registered Nurse 1 (RN1). MD1 stated, ";I think thats about it." MD1 also stated that he signs in on a sign in sheet. During an interview on 5/19/2023 at 10:33 a.m. with the Director of Patient Care Service Designee (DPCSD), the DPCSD stated, ";We do initial meeting to begin the POC (Plan of Care- an individualized care planned for patient) then every 2 weeks." DPCSD was unable to provide the IDG meeting sign in sheet. DPCSD stated, ";There is no sign in sheet, we sign in (HAs Electronic Medical Record – EMR)". A review of facilitys policy and procedure titled, ";Initial Assessment" revised April 2017, indicated ";6. Based on the initial assessment, the plan of care will be initiated on the date of admission." A review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised April 2017, indicated ";5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days. B. If no changes are needed, then that must be documented." A review of facilitys policy and procedure titled, ";Ongoing Comprehensive Assessment" revised April 2017, indicated ";3. Ongoing comprehensive assessment should focus on: D. Changes in patients care environment or support systems. 4. Based on the assessments, the plan of care – including problems, needs, goals, and outcomes – will be reviewed and updated by the interdisciplinary group members responsible for the case." A review of facilitys policy and procedure titled, ";Physician Services-Medical Director" revised April 2017, indicated ";The duties and responsibilities of the Medical Director will include... 3. Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with... interdisciplinary group... including written certification of terminal illness. 6. Reviewing and updating the plan of care every 15 days, or more frequently as needed in conjunction with the attending physician and interdisciplinary group." A review of facilitys policy and procedure titled, ";The Plan of Care" revised April 2017, indicated ";The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days... This plan must be initiated at start of care...5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care." A review of facilitys policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" revised April 2017, indicated ";The hospice interdisciplinary team/group members will include, at a minimum: A. Physician. B. Registered Nurse. C. Social Worker. D. Pastoral or other counselor. The interdisciplinary group will: A. Participate in the establishment of the plan of care for each patient admitted... B. Participate in the periodic review and updating of the plan of care for each patient..."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation regarding care planning and coordination of services for patients was met as follows: --- 1. The HA failed to ensure all care services furnished and followed individualized plans of care established by the interdisciplinary team (IDT) by not conducting home visits as indicated in the plan of care for six of 14 sampled patients (Patient 2, Patient 4, Patient 9, Patient 10, Patient 11, and Patient 12). (Refer to L555). 2. The HA failed to ensure three out of 14 sampled patients' (Patient 4, Patient 5, and Patient 8) care givers provided with the patients plan of care (POC) and their medication profile. (Refer to L558). These deficient practices resulted in the HA not providing the services/care as ordered and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life.

Based on interview and record review, the Hospice Agency (HA) failed to ensure a social worker and a chaplain were included in the interdisciplinary group for seven of 14 sampled patients (Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). This deficient practice could potentially prevent the patients from reaching their care planning goals. --- During an interview on 5/17/2023 at 11:28 a.m., the Director of Patient Care Services Designee (DD) stated the IDG members included the doctor, registered nurse, medical social worker, and the chaplain. The DD stated each discipline needed to document their part, and sign electronically in the electronic medical record. The DD stated it was important for the disciplines to document because whatever is discussed, is also a resource to go back and see what was done for the patient. The DD stated the IDG group met every two weeks by phone. During an attendance of the IDG meeting on 5/18/2023 at 3:02 p.m., the meeting was held through a conference call through the phone. During the meeting, there was input from the Doctor and the registered nurse (RN). During the meeting the RN and Doctor were heard talking about two patients (Patient 5) who was experiencing depression. During the meeting, the Chaplain (CP) and Medical Social worker (MSW) were not heard providing input during the meeting. During an interview on 5/19/2023 at 10:26 a.m., the DD stated the Chaplain and MSW were present in the IDG yesterday but did not provide any input in the meeting. During an interview on 5/19/2023 at 10:45 a.m., the DD stated, "Yes, during IDG, we had two patients who were very depressed. Yes, they could benefit from MSW and Chaplain. MSW could provide psychosocial support and the Chaplain could provide spiritual support". During an interview on 5/19/2023 at 11:30 a.m., the DD stated the purpose of the IDG meeting was for all the members to gather and go over the patients condition and offer input. The attendance of the IDG members is validated through the signature on the IDG notes. 1) A record review of Patient 5 (P5) ";Personal Information" indicated a Start of Care date of 2/27/2023 with a primary diagnosis of secondary malignant neoplasm of unspecified site (cancer of the unknown). During a record review on 5/17/2023 at 11:10 a.m., P5s electronic medical record was reviewed. The records did not indicate the Medical Social Worker (MSW) and the Chaplain (CP) had participated in the IDG meeting on 4/6/2023, 4/20/2023, and 5/4/2023. 2) A record review of Patient 8 (P8) ";Personal Information" indicated an SOC date of 4/12/2023 with a primary diagnosis of chronic ischemic heart disease (heart weakening caused by reduce blood flow to the heart). During a record review on 5/17/2023 at 12:00 p.m., P8s electronic medical record was reviewed. The records did not indicate a spiritual counselor (SC) had participated in the IDG meeting on 4/12/2023, 4/20/2023, and 5/4/2023. 3) A record review of Patient 9 (P9) ";Personal Information" indicated an SOC date of 7/7/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a record review on 5/17/2023 at 12:00 p.m., P9s electronic medical record was reviewed. The records did not indicate an SC had participated in the IDG meeting on 5/4/2023, 4/20/2023, 4/6/2023, 3/23/2023, and 3/9/2023. 4) A record review of Patient 10 (P10) ";Personal Information" indicated an SOC date of 11/12/2022 with a primary diagnosis of Alzheimers Disease. During a record review on 5/17/2023 at 12:15 p.m., P10s electronic medical record was reviewed. The records did not indicate the SC and MSW (Medical Social Worker) had participated in the IDG meeting on 5/4/2023, 4/20/2023, 4/6/2023, 3/23/2023, and 3/9/2023. 5) A record review of Patient 11 (P11) ";Personal Information" indicated an SOC date of 5/5/2022 with a primary diagnosis of Alzheimers Disease. During a record review on 5/17/2023 at 12:30 p.m., P11s electronic medical record was reviewed. The records did not indicate an SC had participated in the IDG meeting on 5/4/2023, 4/20/2023, 4/6/2023, 3/23/2023, and 3/9/2023. 6) A record review of Patient 12 (P12) ";Personal Information" indicated an SOC date of 6/20/2022 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (coronary artery disease due to atherosclerosis is the buildup of fatty plaque along the walls of the arteries, which causes reduced blood flow to the hear causing chest pain). During a record review on 5/17/2023 at 12:45 p.m., P12s electronic medical record was reviewed. The records did not indicate an SC had participated in the IDG meeting on 5/4/2023, 4/20/2023, 4/6/2023, 3/23/2023, and 3/9/2023. 7) A record review of Patient 13 (P13) ";Personal Information" indicated an SOC date of 5/17/2022 with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure, which increases the workload on the heart inducing structural and functional changes). During a record review on 5/19/2023 at 11:40 p.m., P13s electronic medical record was reviewed. The records did not indicate an SC had participated in the IDG meeting on 12/1/2022, 12/15/2022, and 12/29/2022. The records did not indicate the MSW participated in the IDG meeting on 12/15/2022. A review of facilitys policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" revised April 2017, indicated ";The hospice interdisciplinary team/group members will include, at a minimum: A. Physician. B. Registered Nurse. C. Social Worker. D. Pastoral or other counselor. The interdisciplinary group will: A. Participate in the establishment of the plan of care for each patient admitted... B. Participate in the periodic review and updating of the plan of care for each patient..." A review of facilitys policy and procedure titled, ";The Plan of Care" revised April 2017, indicated ";The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days... 5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care."

Based on interview and record review, the Hospice Agency (HA) failed to provide a "Comfort Kit" (a prescribed set of medications that are kept in a patient's home in the event of an emergency) for two out of 14 sampled patients (Patient 6 and Patient 13). This failure had the potential to result in patients not receiving their comfort medications when needed on a timely basis. --- During an interview on 5/17/23 at 11:30 a.m., the Director of Patient Care Services Designee (DD) stated there was a pre-set comfort kit (a series of medication used at the end of life to promote comfort) that was sent to patients initially if they need it, depending on their condition. Otherwise, we hold it. The DD stated once patient starts to decline, we get an order from the doctor, and we send the kit right away. The DD stated the comfort kit should include acetaminophen (mild pain reliever), atropine (control secretions), morphine (moderate to severe pain reliever), bisacodyl (to relieve constipation), Ativan (to relieve anxiety), and Zofran (to relieve nausea). 1) A record review of Patient 6 (P6) ";Personal Information" indicated a Start of Care date of 12/3/2022 and a discharge date of 12/6/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a record review of P6s undated record titled, ";Current Treatment/Medication/DME List" was reviewed. The record did not list atropine, morphine, Ativan, and Zofran. 2) A record review of Patient 13 (P13) ";Personal Information" indicated an SOC date of 5/17/2022 with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure, which increases the workload on the heart inducing structural and functional changes). During a record review on 5/19/2023 at 1:55 p.m., P13s undated record titled, ";Current Treatment/Medication/DME List" was reviewed. The record did not list atropine, morphine, bisacodyl, Ativan, and Zofran. During an interview on 5/19/2023 at 2:00 p.m., nursing representation to review the clinical records and care was requested. The owner (OW) stated the DD was gone for the day and no other nurse was available to come in. A record review of P13s clinical record titled, ";Discharge Summary", dated 1/11/2023, indicated, ";Reason for Discharge: Hospitalized, EOC (end of care) 1/11/2023...On 1/11/2023, PCG (Primary Care Giver) revoked hospice and went to Hospital. Patient passed away same day in the ER (Emergency Room). MD (doctor) order received to discharge patient due to revocation of hospice benefits and hospitalization." A record review of facilitys policy and procedure titled, ";Rights/Responsibilities" revised April 2017, indicated ";M. The right to pain management and symptom control."

Based on interview and record review, the Hospice Agency (HA) failed to ensure all care services furnished and followed individualized plans of care (POC – an individualized plan that maps out the needs and services supplied to patient and their care givers) established by the interdisciplinary team (IDT) by not conducting home visits as indicated in the POC for six of 14 sampled patients (Patient 2, Patient 4, Patient 9, Patient 10, Patient 11, and Patient 12). This deficient practice resulted in the patients not receiving care/services from the home visits and placed the patients at risk by not being provided care/services when they needed. --- 1) A record review of Patient 2 (P2) ";Personal Information" indicated a Start of Care (SOC) date of 4/14/2023 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a record review of P2s POC dated 5/17/2023, indicated ";RN (Registered Nurse) – initial evaluation then every 14 days thereafter for ongoing comprehensive assessment and supervisory visit." During a record review of P2s Electronic Medical Record (EMR), indicated there was one Registered Nurse (RN) visit documented entry made on 4/14/2023. During a concurrent interview and record review on 5/19/2023 at 12:30 p.m. with the Director of Patient Care Services Designee (DD) of P2s EMR, DD stated, ";There are two visits missing for this patient. No, they have not been following the plan of care. The POC should be followed because its there to be followed. We need to supervise LVN and make sure the family is happy with their performance. The RN has to see the patient every 14 days, the RN needs to supervise the case, the patient, and make her visit." 2) A record review of Patient 4 (P4) ";Personal Information" indicated an SOC date of 3/1/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (the buildup of fatty material, called plaque, along the walls of the arteries). During a record review of P4s POC dated 5/17/2023, indicated ";RN (Registered Nurse) – initial evaluation then every 14 days thereafter for ongoing comprehensive assessment and supervisory visit." During a record review of P4s Electronic Medical Record (EMR), indicated the RN assessment/visit note dated 5/10/2023 was blank. During an interview on 5/19/2023 at 10:33 a.m. with DD, DD stated that nursing needed to turn in their documentation ";by 72 hours". 3) A record review of Patient 9 (P9) ";Personal Information" indicated an SOC date of 7/7/2022 with a primary diagnosis of Alzheimers Disease. During a concurrent interview and record review on 5/18/2023 at 11:30 a.m., P9s record titled, ";Plan of Care", dated May 18, 2023, was reviewed with DD. The record indicated, ";SN (Skilled Nurses) 1x/week (one time per week) effective on week of 7/10/22 to promote comfort and symptom management, HA (Hospice Aide) 2x/week (two times a week) to assist with personal care and promote comfort per RN (Registered Nurse) assignment...MSW (Medical Social Worker) once monthly to provide psychosocial support to patient and family. The DD stated according to the POC, the SN is supposed to see the patient once a week, the HA twice a week, and the MSW once a month. The DD stated P9s skilled nursing notes were not in the electronic medical record because P9 was being seen by a nurse contracted through an agency. The DD stated a different nurse sees P9 every week and the agency had hard copies of the notes. The notes were requested and were not provided on 5/18/2023. There was no evidence in P9s record she was receiving SN services as indicated in the POC. During an interview on 5/18/2023 at 11:36 a.m., the owner (OW) stated the agency has not had time to upload the documents in the record because the agency has been busy with the Joint Commission (an accreditation agency) in September, CMS (Centers for Medicaid Services) comes every week, and then you guys. The OW stated, we have not had a break, pretty much its your guys fault. During a concurrent interview and record review on 5/18/2023 at 11:38 a.m., P9s electronic medical record was reviewed with the DD. The DD stated the last note documented by the HA was on February 22, 2023. The DD stated HA has not written her notes, but she has been going. During an interview on 5/18/2023 at 11:47 a.m., the Intake Coordinator (IC) stated she would check to see if the HA had submitted routing sheets (a document requiring a patients signature to validate the visit occurred). No routing sheets by the HA were provided to the surveyors. There was no evidence in P9s record that she was receiving HA services as indicated in the POC. During a concurrent interview and record review on 5/18/2023 at 12:00 p.m., P9s electronic medical record was reviewed with the DD. The DD stated the MSW was only for the initial visit because the patient did not want any MSW services after that. The DD stated the POC was wrong, it should not say that frequency. The DD stated the last MSW visit documented in P9s medical record was on 1/20/2023. During an interview on 5/18/2023 at 12:07 p.m., the IC stated the MSW was seeing P9. The IC stated P9 sometimes didnt want the MSW to visit her. The IC asked, ";does the MSW need to document she didnt go? I called the MSW. She said she called the patient to offer services and the patient didnt need anything. The MSW said she only documents if she visited the patient, or the patient needed MSW services." During a concurrent interview and record review on 5/18/2023 at 12:08 p.m., P9s record titled, ";POC/IDG Review", dated May 4, 2023, was reviewed with the DD. The record indicated, ";Frequency of visit...Psychosocial: MSW will continue working on enhancing coping strategies and will continue to provide psychosocial support to the patient and family". The DD stated the MSW needed to document that she called the patient to follow up and what the result of the conversation was. That way, when we discuss in IDG, we know what the situation is. 4) A record review of Patient 10 (P10) ";Personal Information" indicated an SOC date of 11/12/2022 with a primary diagnosis of Alzheimers Disease. During a concurrent interview and record review on 5/18/2023 at 1:01 p.m., P10s record titled, ";Plan of Care", dated May 17, 2023, was reviewed with the DD. The record indicated, ";Frequency of visit...MSW once monthly to provide psychosocial support to patient and family...SC (Spiritual Care) once a month to provide spiritual support to patient and family...". The DD stated P10 was not receiving chaplain and MSW services because the patient declined. The DD stated the plan of care (POC) was not updated and could not provide an explanation. The DD stated it was important to update the POC because the disciplines need to know how often to provide the discipline. The DD stated we also provide a POC for the patients. If they are not receiving an updated POC, the information is not correct. When asked if the POC is supposed to be updated during the IDG (Interdisciplinary Group consisting of Doctor, Registered Nurse, MSW, and Spiritual Counselor) meeting, the DD stated, ";I agree, I dont know what to say": the IDGs is an opportunity to update the plan of care. There was no evidence in P10s record that SC and MSW services were given as indicated in the POC. 5) A record review of Patient 11 (P11) ";Personal Information" indicated an SOC date of 5/5/2022 with a primary diagnosis of Alzheimers Disease. During a concurrent interview and record review on 5/19/2023 at 12:06 p.m., P11s record titled, ";Plan of Care", dated May 17, 2023, was reviewed with the DD. The record indicated, ";Frequency of visit...SC - Chaplain will continue to follow up once monthly to provide spiritual support to patient and family." Further review of the record indicated, ";Spiritual Goal-Patient will receive spiritual support such as prayers and scripture reading to adequately cope with suffering and the afterlife and will receive inner peace and Gods presence...". The DD stated the last time the SC visited P11 was on 11/1/2022. The DD stated there was no visits after 11/1/2022 and did not know why. 6) A record review of Patient 12 (P12) ";Personal Information" indicated an SOC date of 6/20/2022 with a primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (coronary artery disease due to atherosclerosis is the buildup of fatty plaque along the walls of the arteries, which causes reduced blood flow to the hear causing chest pain). During a concurrent interview and record review on 5/19/2023 at 12:08 p.m., P12s record titled, ";Plan of Care", dated May 18, 2023, was reviewed with the DD. The record indicated, ";Frequency of visit...MSW every recertification to provide psychosocial support to patient and family." The DD stated P12 did not have an MSW recertification visit for the current certification period of 4/16/2023. DD stated the MSW should have seen him around the time of 4/16/2023. A review of facilitys policy and procedure titled, ";Ongoing Comprehensive Assessment" revised April 2017, indicated ";2. The nurse will assess the patient on each visit, for: P. Progress toward hospice goals and patient needs and problems. 4. Based on the assessments, the plan of care – including problems, needs, goals, and outcomes – will be reviewed and updated by the interdisciplinary group members responsible for the case." A review of facilitys policy and procedure titled, ";The Plan of Care" revised April 2017, indicated ";The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments... This plan must be initiated at start of care...4. The plan of care will identify the patients needs and services to meet those needs..." A review of facilitys policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" revised April 2017, indicated ";The interdisciplinary group will: A. Participate in the establishment of the plan of care for each patient admitted... B. Participate in the periodic review and updating of the plan of care for each patient..." A review of facilitys policy and procedure titled, ";Missed Visits" revised April 2017, indicated ";A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record." A review of facilitys policy and procedure titled, ";Admission Criteria and Process" revised April 2017, indicated ";5. H. Provide services, as needed, and ordered by physician..." A review of facilitys policy and procedure titled, ";Timely Submission of Patient Documentation" revised April 2017, indicated ";1. Physicians orders must be submitted to Agency within three (3) business days after receipt. 2. Itineraries, with all visit reports attached, must be submitted the next scheduled workday, not exceeding three (30 business days. All patient visit reports from contract personnel must be submitted within three (3) business days from the date of the visit..."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure three out of 14 sampled patients (Patient 4, Patient 5, and Patient 8) Care Givers (CG) be provided with the patients plan of care (POC) which provided information on the services/care being provided by the HA and a current medication list. This failure had the potential to result in placing the patients at risk for not receiving the services/care stated in their individualized POC. --- a) A record review of Patient 4 (P4) ";Personal Information" indicated a Start of Care date of 3/1/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (the buildup of fatty material, called plaque, along the walls of the arteries). During a joint home visit on 5/17/2023 at 11:10 a.m. with License Vocational Nurse (LVN1) of P4s home, P4s hospice folder contained his Plan of Care (POC – an individualize plan of care and treatment) with a printing date of 5/16/2023 together with a current medication list inside. LVN1 stated, ";To tell you the truth, the Registered Nurse (RN) either (RN1) or (RN2) bring the POC and the medication list." LVN1 stated that she completes her medication reconciliation using her phone. LVN1 also stated, ";They need their POC to know what care they are going to get." b) A record review of Patient 5 (P5) ";Personal Information" indicated an SOC date of 2/27/2023 with a primary diagnosis of secondary malignant neoplasm of unspecified site (cancer of the unknown). During a joint home visit on 5/17/2023 at 10 a.m. with License Vocational Nurse (LVN2) of P5s home, P5s hospice folder did not contain her POC or a current medication list. LVN2 stated, ";I dont know why there is no current list here." LVN2 was noted placing a POC dated 5/16/2023 and current medication list inside P5s hospice folder. c) A record review of Patient 8 (P8) ";Personal Information" indicated an SOC date of 4/12/2023 with a primary diagnosis of chronic ischemic heart disease (heart weakening caused by reduce blood flow to the heart). During a concurrent observation and interview of the home visit on 5/17/2023 at 2:05 p.m., Licensed Vocational Nurse 1 (LVN1) was observed providing care to P8. During the visit, a plan of care (POC) document was observed in P8s folder. The POC read ";Plan of Care", dated May 16, 2023". P8 stated someone came to the home to drop off the document and did not know who it was. LVN 1 stated she did not know who came because she has been on survey. LVN 1 stated the POC was dated May 16, 2023. During an interview on 5/18/2023 at 11:35 a.m., the Director of Patient Care Services Designee (DD) stated it was important for the POC to be at home so everyone, family, patient, nurses can have access to information regarding the care of the patient. During an interview on 5/19/2023 at 11:30 a.m. with the Director of Patient Care Services (DD), the DD stated, ";We put the medication list to make sure the patient, family, and nurse to see. The DD stated when our nurse goes, she does the reconciliation and organizes the medication for the patient. Sometimes medications are discontinued, or patients stop taking medication, its important for the patient to take right dose, right time, and right medication." DD also stated, ";POC is printed and its in the patients chart for the LVN to follow. The DD stated whatever is in the plan of care, the LVN needs to follow. She does have access to hospice MD as well. All disciplines need to know, God forbid the patient is in the emergency room or the nurse needs to be covered by another nurse." A review of facilitys policy and procedure titled, ";Physician Services-Medical Director" revised April 2017, indicated ";The duties and responsibilities of the Medical Director will include... 3. Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with... interdisciplinary group... including written certification of terminal illness." A review of facilitys policy and procedure titled, ";Admission Criteria and Process" revised April 2017, indicated ";7. If eligibility criteria are met, the patient and family/caregiver will be provided with... materials providing sufficient information on: A. nature and goals of care and/or services." A review of facilitys policy and procedure titled, ";Medication Profile" revised April 2017, indicated ";5. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver as well as other clinicians, understand the medication regimen..."

Based on interview and record review, the Hospice Agency (HA) failed to ensure two of 14 sampled patients (Patient 6 and Patient 7) family had bereavement counseling postmortem. This failure resulted in families/care givers did not receive the bereavement services after their family member passed away. --- 1) A record review of Patient 6 (P6) ";Personal Information" indicated a Start of Care date of 12/3/2022 and a discharge date due to death of 12/6/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During an Electronic Record Review (EMR) of P6s medical record on 5/17/2023, the record indicated there was no initial bereavement assessment, bereavement plan of care, post death bereavement assessment, bereavement letters, or post death bereavement support documented. 2) A record review of Patient 7 (P7) ";Personal Information" indicated an SOC date of 12/1/2022 and a discharge date of 12/7/2022 with a primary diagnosis of Alzheimers Disease. During an Electronic Record Review (EMR) of P7s medical record on 5/17/2023, the record indicated there was no initial bereavement assessment, bereavement plan of care, post death bereavement assessment, bereavement letters, or post death bereavement support documented. During an interview on 5/19/2023 at 10:20 a.m. with the Director of Patient Care Services Designee (DD), DD stated, ";Bereavement assessment, they do it once the chaplain does the initial assessment, he does the bereavement as well. They do initial bereavement within five days; he needs to get to know the family. Assess the relatives of the patient how they will cope with the patients illness if they need any help to give them support." DD also stated, ";Post death family support. We need to provide bereavement. The chaplain needs to contact the family at one (1), three (3), six (6), and 12 months. Its not in (EMR), its missing the bereavement letters. After patient dies, family is still grieving and they need help and support, and the chaplain needs to help them." A review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised April 2017, indicated ";1. During the comprehensive assessment patient assessment, all baseline data and other relevant information will be documented in the patients clinical record...as relevant... R. The patients psychosocial status... T. An assessment of the patients and family/caregivers spiritual orientation... W. A bereavement assessment of the needs of the patients family 2. The assessment should determine: E. Anticipated discharge needs, including bereavement..." A review of facilitys policy and procedure titled, ";Ongoing Comprehensive Assessment" revised April 2017, indicated ";2. The nurse will assess the patient on each visit, for: P. Progress toward hospice goals and patient needs and problems. N. Spiritual needs. O. Additional psychosocial issues. 4. Based on the assessments, the plan of care – including problems, needs, goals, and outcomes – will be reviewed and updated by the interdisciplinary group members responsible for the case." A review of facilitys policy and procedure titled, ";Bereavement Assessment" revised April 2017, indicated ";(HA) will provide bereavement services for up to one year after the patients death to surviving family/caregiver members. 3. Bereavement needs will be reassessed during each contact. 4. After the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment. 5. The Bereavement Coordinator will develop a plan for intervention, based on the findings of the bereavement follow-up assessment and input from interdisciplinary group members." A review of facilitys policy and procedure titled, ";Bereavement services" revised April 2017, indicated ";(HA) will provide an organized bereavement program... The program will provide bereavement services to the family/caregiver or hospice patients, before and after the patients death, in accordance with the plan of care. 8. Within two (2) weeks after the death of a patient, a sympathetic card will be sent to the bereaved. 9. After three (3) weeks, a bereavement letter will be sent to the bereaved..."

Based on interview and record review, the Hospice Agency (HA) failed to provide all core services including nursing services for one of 14 sampled patients (Patient 9). This deficient practice placed the patient and family member at risk of not having physical, emotional, and spiritual care needs met due to lack of continuity of care. --- A record review of Patient 9 (P9) ";Personal Information" indicated a Start of Care date of 7/7/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During an interview on 5/18/2023 at 11:30 a.m., the Director of Patient Care Services Designee (DD) stated P9 was being cared for by a staffing agency nurse. The DD stated a different nurse sees P9 every week and the agency had hard copies of the notes. During an interview on 5/19/2023 at 2:52 p.m., the owner (OW) stated the Hospice Agency (HA) was using a staffing agency for nursing care because the HA cannot find nurses to hire. The OW stated the HA was not a rural agency and did not have a waiver for using contracted staff. The OW stated he did not know hospice agencies could not use contracted nursing staff. A review of facilitys policy and procedure titled, ";The Plan of Care" revised April 2017, indicated ";12. Core hospice services (nursing, social work, physician, and counselors) will be available 24 hours a day, seven (7) days a week..." A review of facilitys policy and procedure titled, ";Listing of Services Provided" revised April 2017, indicated ";2. Services will be provided as listed below: Directly – Registered Nurse, Licensed practical/vocational nurse, medical social worker, hospice aide, volunteers, spiritual care counselor services, bereavement services, physician services/Medical Director."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Medical Director was met as follows: --- 1. Hospice Agency (HA) failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care for three of 14 sample patients (Patient 2, Patient 5, and Patient 8). For Patient 2, the Medical Director has no signature, and the certification of terminal illness (CTI) narrative notes/assessment was completed by an the Registered Nurse (RN). For Patient 5, there was no documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice are and services. For Patient 8, there was no written certification that the patient's life expectancy is 6 months or less if the illness runs its normal course. (Refer to L 667). 2. The HA failed to ensure medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs for recertification of hospice care benefits for continued hospice care and services for two of 14 sample patients (Patient 3 and Patient 12). (Refer to L 668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care for three of 14 sample patients (Patient 2, Patient 5, and Patient 8). For Patient 2, the Medical Director has no signature and the certification of terminal illness (CTI) narrative notes/assessment was completed by an the Registered Nurse (RN). For Patient 5, there was no documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice are and services. For Patient 8, there was no written certification that the patient's life expectancy is 6 months or less if the illness runs its normal course. These deficient practices resulted in the hospice medical director and/or the hospice attending physicians certified the patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses and could result to lack and inappropriate care provided to the patients. --- a.) A review of Patient 2 (P2) ";Personal Information" indicated a Start of Care (SOC) dated 4/14/2023 with a primary diagnosis of Alzheimers disease (generalize degeneration of the brain). A review of P2s Electronic Medical Record (EMR) document titled, ";Physician's Certification for Hospice Benefit (CTI – certification of terminal illness: a brief narrative completed by a medical doctor)" for certification period 4/14/2023 to 7/12/2023, indicated, the Medical Directors (MD1) name was on the form. It also indicated the first and third paragraph in section ";RN Prognosis Summary" and section ";Certifying Physician Summary" contained the same word per word documentation. During a telephone interview on 5/18/2023 at 12:15 p.m., MD1 stated, ";This patient has Alzheimers disease and P2s medical insurance contacted the agency for admission, and provided the Alzheimers diagnosis. MD1 stated, ";I saw that the patient has Alzheimers, on the authorization. I also checked the patient and based on my exam she was having a lot of weakness. She was having a lot of issues maintain nutrition and stuff like that. If the question, how do I determined, depending on their diagnosis. The authorization was faxed over, I dont know if they faxed the history..." MD1 stated that they were still waiting for P2s medical insurance to fax over P2s medical history. MD1 stated, ";I reviewed the nursing assessment and also the physical..." During a concurrent telephone interview and record review on 5/18/2023 at 12:26 p.m. with MD1 of P2s Electronic Medical Record (EMR) section ";CTI", MD1 stated, ";I use the nursing assessment...I think what happened for this patient, I think I was like not very good with the computer. I told the nurse to write it. I told him to write certain stuff. I believed this was (RN2). I did not know where the CTI was, so I told her to write it. I am trying to do these things as I go. I had her write it down for me. I dont think she has my username, maybe I was there with her. I told her certain thing to put in there." Lastly MD1 stated, ";Its different what the nurses and the physician write." b.) A review of Patient 5 (P5) ";Personal Information" indicated a Start of Care dated 2/27/2023 with a primary diagnosis of secondary malignant neoplasm of unspecified site (cancer of the unknown). A review of P5s Electronic Medical Record (EMR) document titled, ";Physician's Certification for Hospice Benefit (CTI – certification of terminal illness: a brief narrative completed by a medical doctor)" on 5/17/2023, for certification period 2/27/2023 to 5/27/2023, indicated the Medical Directors (MD1) name was on the form. It also indicated it was not signed by MD1. Lastly, MD1 wrote ";Ms. ... with stage 4 cancer and metastatic disease." Site of cancer was not documented on the CTI. A record review of P5s EMR document titled ";Physician's Certification for Hospice Benefit" for certification period 2/27/2023 t o5/27/2023, provided by the Intake Coordinator (IC) on 5/18/2023, indicated MD2s name and electronic signature were on the CTI form. Section ";Certifying Physician Summary" did not contain written certification that the patient's life expectancy of 6 months or less if the illness runs its normal course. The CTI form indicated, ";Life expectancy short, prognosis is poor." Lastly, MD2 wrote ";Ms. ... with stage 4 cancer and metastatic disease." Site of cancer was not documented on the CTI. During a concurrent interview and record review on 5/19/2023 at 11:20 a.m. with the Director of Patient Care Services Designee (DD) of P5s EMR, DD stated, ";The referral came from the hospital and its impossible to have hospital sign. They will never sign this form and fax it back to us. Physician certifies patient for hospice, he approves the patient to be in hospice. Its supposed to be done initially, to have the doctors approval to proceed with hospice services. Physicians narrative is supposed to be documented on the physicians narrative. I am not aware if anyone dictates for him." During a telephone interview on 5/18/2023 at 12:15 p.m. with MD1, MD1 stated that he reviews patients referral and medical history to see if ";they have a diagnosis consistent with hospice." MD1 also stated, ";I use the nursing assessment as part of, a lot of it is the important information to fill out as hospice." c.) A record review of Patient 8 (P8) ";Personal Information" indicated a Start of Care date of 4/12/2023 with a primary diagnosis of chronic ischemic heart disease (heart weakening caused by reduce blood flow to the heart). During an interview and record review on 5/17/23, at 12:21 p.m., of P8s record titled, ";Physicians Certification for Hospice Benefit", dated 4/12/2023 to 6/10/2023, was reviewed with the owner (OW). The record indicated, ";Referring Physician Attestation: It is my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course.". The record further indicated MD 3 was listed under section titled, ";Physician Name", section ";Signature" and ";date" were not recorded. The OW stated the signature of the referring doctor was not required because the referring doctor does not have access to the facilitys Electronic Medical Record (EMR). During a joint home visit on 5/17/23, at 1:55 p.m., P8s care was observed. P8 was lying in bed, and independently sat up to the side of the bed. P8 was observed breathing normally, without any signs of distress. During an interview during the home visit on 5/17/23, at 2:00 p.m., P8 stated he went to the dentist earlier, using a taxi because the person who normally drives him to doctors appointments was involved in an accident. P8 stated he went to the dentist by himself. P8 stated he had a primary care physician and informed him, his condition was fine and was doing well. P8 stated he has been on dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) for 4 years. P8 stated, he did not know what hospice care and services all about. During an interview during the home visit on 5/17/23, at 2:20 p.m., P8 stated he uses a cane to go walk outside. P8 stated he enjoys walking outdoors, in the sidewalk of the streets. P8 stated he walks to ";San Fernando" street. During an interview on 5/18/23, at 12:15 p.m., the Medical Director 1 (MD 1) stated his process for certifying patients for hospice care was to look at the patients information such as medical history to see if there was a diagnosis consistent with hospice. Next, the nurses will go out and assess the patient. MD 1 stated the nurses assessment was very important. MD 1 stated he had to evaluate it through person or through a secure video conference. MD 1 stated, the big thing is their PPS (Palliative Performance Scale, a tool used to measure functioning and disease progression in adults with chronic conditions), KPS score (a tool used for predicting the length of survival in terminally ill patients), depending on the diagnosis, and the level of the score, just to be sure the patients meet the criteria. MD 1 stated he was very strict to make sure the patient has 6 months or less to live, of criteria. MD 1 stated he documented his own findings in the medical record. MD 1 stated he made his own notes and transcribed it in the computer in the facilitys Electronic Medical Record (EMR). During an interview on 5/18/23, at 12:25 p.m., MD 1 stated he had reviewed P8s medical history. MD 1 stated P8 has history of hemiparesis (weakness on one side of the body) due to a stroke (brain attack). MD 1 stated it was obvious P8 needed a lot of help for his ADLs (activities of daily living), and he was losing weight. MD 1 stated, ";yes, I looked at his medical records. They (the hospice) sent it to me securely." During an interview on 5/19/23, at 9:25 a.m., P8s authorized representative (AR) stated she was not related to P8. The AR stated her relationship to P8 was as a caregiver until November 2022. During an interview on 5/19/23, at 9:31 a.m., the Home Health Case Manager (HHCM), stated P8 was discharged from the Home Health Agency (HHA) in April 2023 because P8s family requested hospice care. The HHCM stated the HHA referred the patient to hospice care. During an interview on 5/19/23 at 10:47 a.m., the Mobile Doctor Representative (MR) stated Medical Doctor 3 (MD 3) was not available and all communication/inquiries need to go through her. The MR stated she would provide all information requested and it is not possible to speak with the doctor because ";he is busy". The MR stated P8 was last seen by MD 3 on 2022 and has not had any visit since then. The MR stated ";No, I believe doctor did not refer him to hospice care. I dont see it on my end". During a concurrent interview and record review on 5/19/23 at 11:15 a.m., P8s record titled, ";Physician Order", dated 4/12/23, was reviewed with the Director of Patient Care Services Designee (DD). The record indicated, ";Orders Received a call from patients family who report the patient will be starting hospice care." When asked to provide an explanation of the record, the DD called P8s nurse to inquire about information regarding P8s primary care giver. DD stated P8 had a daughter but was not involved in P8s care. During a concurrent interview and record review on 5/19/23, at 2:19 p.m. P8s record titled ";Audit Log" (a document that indicates the details of the changes made to a record), dated 4/12/23 to 5/18/23, was reviewed with the OW. The record indicated, ";Modified Date 5/1/2023", ";staff" the OW was listed, ";Module Certification MD", ";Visit date 4/12/2023", Field/Section Physician Narrative: Certifying Physician Summary: This is an elderly gentleman...he has confusion, forgetfulness, and disorientation...he has lost his independence...he is weak, dizzy, unsteady on his feet and high risk for fall...he has lost close to 10% if his body weight...". The OW stated he did not log into P8s record to document. The OW stated he did log in to look at the records to see if its finished or not. The OW stated he might have changed the document like capitalizing sentences. The OW stated it could be possible that the doctor logged into the computer in the office, because the OW does not log off the computer and the doctor could have documented on P8s record using the OWs username and password. During a concurrent interview and record review on 5/19/23 at 3:35 p.m., P8s HHA document titled, ";Patient, Facility", dated 10/14/22, was reviewed with the OW. The OW stated this document was the medical records sent to the agency for P8. The OW reviewed the documents and stated, ";no, it does not say that he has a terminal illness, or he is hospice candidate." A review of facilitys policy and procedure titled, ";Physician Services-Medical Director" revised April 2017, indicated ";The duties and responsibilities of the Medical Director will include... 3. Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with... interdisciplinary group... including written certification of terminal illness. 12. Documenting care provided in the patients clinical record, providing evidence of progression of the end-stage disease process." A review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised April 2017, indicated ";4. The Clinical Supervisor/Nursing Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis." A review of facilitys policy and procedure titled, ";The Plan of Care" revised April 2017, indicated ";The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments... 6. The hospice Medical Director will need to review the patients history and physical... to be able to sign the certification of terminal illness section of the plan of care. A review of facilitys policy and procedure titled, ";Admission Criteria and Process" revised April 2017, indicated ";The patients life-limiting illnesses and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). A review of facilitys policy and procedure titled, ";Certification of Terminal Illness" revised April 2017, indicated ";Patient who elect the hospice Medicate or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course by the... Medical Director. 1. At the time of admission to hospice, the hospice Medical Director... 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. 3. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification." A review of facilitys policy and procedure titled, ";Medical Record Content" revised April 2017, indicated ";The Agency will initiate and maintained and individual and accurate medical record for each patient receiving care... Each medical record will contain the following: - Patient history relevant to admission. -Primary and secondary diagnosis related to the patient care as assessed upon admission and updated during the course of care."

Based on interview and record review the Hospice Agency (HA) failed to ensure medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs for recertification of hospice care benefits for continued hospice care and services for two of 14 sample patients (Patient 3 and Patient 12). This deficient practice resulted in the hospice agency claiming reimbursement for patients who did not need hospice care and service and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- a.) A review of Patient 3 (P3) ";Personal Information" indicated a Start of Care date of 11/23/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). A review of P3s ";Comprehensive Nursing Assessment" visit date 11/23/2022, indicated P3s MAC (Mid Arm Circumference – measure that can be used to determine lean body mass and fat reserves) was 38 on right arm. A review of P3s medical record document titled, ";Local Coverage Determination (LCD) Hospice eligibility Determination" dated 5/10/2023, indicated ";Dementia due to Alzheimers (1 must be met and at least on of the conditions in 2). 2. Documented history/progression of at least any one of the following". Section 2 had yes under section f. ";Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin <2.5gm/dl? YES". A record review of P3s medical record document titled, ";Physician's Certification for Hospice Benefit (CTI – certification of terminal illness: a brief narrative completed by a medical doctor)" on 5/17/2023, for certification period 2/21/2023 to 5/21/2023, indicated the Medical Directors (MD2) certified that P3 has a ";life expectancy of 6 months or less if her terminal illness runs its normal course." A record review of P3s medical record document titled ";Visit Note LVN" dated 5/12/2023, 5/5/2023, 4/28/2023, 4/21/2023, and 4/14/2023 indicated, P3s MAC is 38. A record review of P3s ";POC (plan of care)/IDG (Interdisciplinary group) Review" dated 5/4/2023, did not indicate P3s weight or weight loss was mentioned. A record review of P3s ";POC (plan of care)/IDG (Interdisciplinary group) Review" dated 3/9/2023, did not indicate P3s weight or weight loss was mentioned. A record review of P3s History and Physician from her Medical Center dated 11/22/2022, did not indicate or mentioned P3s weight or weight loss. During a concurrent interview and record review on 5/19/2023 at 12:50 p.m. with the Director of Patient Care Services Designee (DD) of P3s Electronic Medical Record - LCD eligibility, DD stated, ";It determines if patient qualifies or not for hospice care. Weight loss – if eligibility compliance is done on the day of admission. We needed to add that information on admission from somewhere, let me look at the H&P (history and physical). I cant find that it says weight loss on her H&P." DD was asked if P3 had any weight loss since being admitted to the HA. DD stated, ";I dont see anything different. The MAC auto populates." During a telephone interview on 5/18/2023 at 12:15 p.m. with MD1, MD1 stated that he reviews patients referral and medical history to see if ";they have a diagnosis consistent with hospice." MD1 also stated, ";I use the nursing assessment as part of, a lot of it is the important information to fill out as hospice." b.) A record review of Patient 12 (P12) ";Personal Information" indicated a Start of Care date of 6/20/2022 with a primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified ang pectoris (coronary artery disease due to atherosclerosis is the buildup of fatty plaque along the walls of the arteries, which causes reduced blood flow to the hear causing chest pain.) During an interview on 5/18/23, at 12:15 p.m., the Medical Director 1 (MD 1) stated his process for Certifying Patients for Hospice Care was to look at the patients information such as medical history to see if there was a diagnosis consistent with hospice. Next, the nurses will go out and assess the patient. MD 1 stated the nurses assessment was very important. MD 1 stated he had to evaluate it through person or through a secure video conference. MD 1 stated he was very strict to make sure the patient has 6 months or less to live, of criteria. MD 1 stated he documented his own findings in the medical record. MD 1 stated he made his own notes and transcribed it in the computer in the electronic medical record (EMR). During an interview on 5/19/23 at 1:30 p.m., P12 stated, he make his own decision for health care services. P12 stated, he did not know what hospice care was and did not know much about it. P12 stated he had the same primary care doctor for at least 17 years, with the most recent appointment being 15 days ago. P12 stated his doctor has not told him anything about his life expectancy. P12 stated his medical problems were not new as he has been having them for 20 years. During an interview on 5/19/23 at 2:00 p.m., nursing representation to review the clinical records and care was requested. The owner (OW) stated the Director of Patient Care Services Designee (DD) was gone for the day and no other nurse was available to come in. During a concurrent interview and record review on 5/19/23 at 2:37 p.m. P12s record titled, ";Audit log", dated 4/1/2023 to 5/19/2023, was reviewed with the OW. The record indicated, ";Modified Date 5/1/23...Staff OW, Module Certification MD, Visit Date 4/16/2023, Field/Section: Physician Narrative: Certifying Physician Summary, Current Value This is a ...with diagnosis of End Stage Heart Disease...". The OW stated it could be possible that the doctor logged into the computer at the office, because the OW does not log off and the doctor could have documented using the OWs username and password. A review of P12s medical record titled, ";Physicians Certification for Hospice Benefit CTI", for dates 4/16/2023 to 6/14/2023, indicated, ";Certifying Physician Summary: this is a...Patient demonstrates progressive health condition decline...Patient has shortness of breath with even minimal physical activity and even at rest...the patient constantly loses weight (more than 10 lbs at last 2 month)... Medical Director Attestation/Certification: I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment, and/or examination of the patient. Reviewed and electronically signed by" (MD 1), ";date 4/14/23". A review of P12s record titled, Re-Cert Assessment, dated 2/13/23, indicated ";Vitals & Measurement Wt", nothing documented. ";MAC (cm) 26.5." No O2 saturation documented. Further review of the record indicated, ";Respiratory: dyspnea-mild, exertion level: w/mild exertion...no respiratory distress during visit. However, episodes of SOB managed with rest, proper positioning..." A review of P12s record titled, Re-Cert Assessment, dated 4/10/23, indicated ";Vitals & Measurement Wt.", nothing documented. ";MAC (cm) 26.5." Further review of the record indicated, ";Respiratory: dyspnea-mild, exertion level: w/mild exertion...O2 saturation 98% room air....no respiratory distress noted and observed during this visit." A review of facilitys policy and procedure titled, ";Physician Services-Medical Director" revised April 2017, indicated ";The duties and responsibilities of the Medical Director will include... 3. Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with... interdisciplinary group... including written certification of terminal illness. 12. Documenting care provided in the patients clinical record, providing evidence of progression of the end-stage disease process." A review of facilitys policy and procedure titled, ";Interdisciplinary group Meeting" revised April 2017, indicated ";7. Patient approaching recertification will be reviewed for the appropriateness of continuation of care based on identifiable criteria and progression of the terminal illness." A review of facilitys policy and procedure titled, ";Certification of Terminal Illness" revised April 2017, indicated ";Patient who elect the hospice Medicate or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course by the... Medical Director. 5. Subsequent recertification, at the beginning of each new benefit period... At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patients medical record or... examination of the patient."

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

Based on interview and record review the hospice agency (HA) failed to ensure that the amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification, for six of 14 sampled patients (Patient 4, Patient 6, Patient 7, Patient 8, Patient 10, and Patient 12). This failure resulted in an unauthorized and inaccurate patient information or assessment entered in the patients medical record that could affect the patients quality of care and well-being. --- 1). A review of Patient 4 (P4) ";Personal Information" indicated a Start of Care date of 3/1/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (the buildup of fatty material, called plaque, along the walls of the arteries.) A record review of P4s record titled, ";Audit log" (a document that indicates the details of the changes made to a record), dated 4/1/2022 to 5/18/2023, indicated ";Modified Date: 5/17/2023 09:02:02 AM, Staff: Registered Nurse 1 (RN1), Module: Certification MD, Visit Date: 4/30/2023, Field/Section: Physician Narrative: Certifying Physician Summary, Current Value was modified from previous value. Module ID: 1407823. Further review of log indicated Medical Director 1 (MD1) signed off on Module ID 1407823 on 5/17/2023 2:15:59 PM. A review of P4s record titled, ";Audit log", dated 4/1/2022 to 5/18/2023, indicated ";Modified Date: 5/17/23...Staff: Registered Nurse 1 (RN1), Module: Certification MD, Visit Date: 4/30/2023, Field/Section: Physician Narrative: Certifying Physician Summary, Current Value was modified from previous value. Module ID: 1377984. 2). A review of Patient 6 (P6) ";Personal Information" indicated a Start of Care date of 12/3/2022 and a discharge date of 12/6/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). It also indicated P6s Referring Doctor (MD3). A review of P6s record titled, ";Audit log", dated 12/1/2022 to 5/19/2023, indicated ";Modified Date: 5/17/23...Staff: Chaplain (CP), Module: Bereavement Assessment, Visit Date: 12/4/2022, Field/Section: Created, Current Value and Previous value were blank. 3). A review of Patient 7 (P7) ";Personal Information" indicated a Start of Care date of 12/1/2022 and a discharge date of 12/7/22 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). A review of Electronic Record Review (EMR) of P7s medical record indicated, there was no initial bereavement assessment, bereavement plan of care, post death bereavement assessment, bereavement letters, or post death bereavement support documented. A review of P7s record titled, ";Audit log", dated 12/1/2022 to 5/19/2023, indicated ";Modified Date: 5/17/23...Staff: Chaplain (CP), Module: Bereavement Assessment, Visit Date: 12/2/2022, Field/Section: Created, Current Value and Previous value are blank. 4a). A review of P8's ";Personal Information" indicated a Start of Care date of 4/12/2023 with a primary diagnosis of chronic ischemic heart disease (heart weakening caused by reduce blood flow to the heart). During an interview on 5/19/23, at 9:25 a.m., P8s authorized representative (AR) stated she was not related to P8. The AR stated her relationship to P8 was as a caregiver until November 2022. During an interview on 5/19/23, at 9:31 a.m., the Home Health Case Manager (HHCM), stated P8 was discharged from the Home Health Agency (HHA) in April 2023 because P8s family requested hospice care. The HHCM stated the HHA referred the patient to hospice care. The HHCM provided the contact information of P8s family. The name and phone number provided were identical as the information in P8s record titled, ";Personal Information", under section ";Authorized Rep (AR), Phone and Personal Information Cell". During a concurrent interview and record review on 5/19/23 at 11:13 a.m., P8s undated record titled, ";Personal Information" was reviewed with the Director of Patient Care Services Designee (DD). The record indicated, ";Authorized Rep (representative)/Emergency Contact (EC)". Further review of the record indicated section ";Personal Information Cell" and ";Phone" of the PCG were the same. The DD stated the AR was P8s primary contact, his daughter. During a concurrent interview and record review on 5/19/23 at 11:15 a.m., P8s record titled, ";Physician Order", dated 4/12/23, was reviewed with the DD. The record indicated, ";Orders Received a call from patients family who report the patient will be starting hospice care." When asked to provide an explanation of the record, the DD called P8s nurse to inquire about information regarding P8s primary care giver. The DD stated P8 had a daughter but was not involved in P8s care. The name of P8s daughter was not provided. The DD stated she did not know who entered the information in P8s record and would follow up with the intake coordinator (IC). 4b). During a concurrent interview and record review on 5/17/23 at 12:21 p.m., P8s record titled ";Physicians Certification for Hospice Benefit", dated 4/12/23-6/120/23, was reviewed with the owner (OW). The record indicated, ";Medical Director Attestation/Certification I attest/confirm that I composed this narrative base on my review of patients medical record, team assessment and or/examination of the patient". Further review of the record indicated, ";Signature on File/Verified by..." OW. The OW stated Signature on file/verified by...meant that he had reviewed the documentation to make sure all the elements were there. The OW stated a signature needed to be there, otherwise, he cannot bill for it. During a concurrent interview and record review on 5/19/23, at 2:19 p.m. P8s record titled ";Audit Log" (a document that indicates the details of the changes made to a record), dated 4/12/23 to 5/18/23, was reviewed with the OW. The record indicated, ";Modified Date 5/1/2023", ";staff" the OW was listed, ";Module Certification MD", ";Visit date 4/12/2023", Field/Section Physician Narrative: Certifying Physician Summary". The OW stated he did not log into P8s record to document. The OW stated he did log in to look at the records to see if its finished or not. The OW stated he might have changed the document like capitalizing sentences. The OW stated it could be possible that the doctor logged into the computer in the office, because the OW does not log off the computer and the doctor could have documented on P8s record using the OWs username and password. The OW stated failing to log off is not a good practice as patients privacy is the first thing that comes to mind. The OW stated accurate patient record keeping means: staff should write whatever is right for the patient, whatever they see they should document. Authentication means the staff write the note, the date they saw the patient, and electronically sign. 4c). During an interview on 5/17/23 at 11:30 a.m., the DD asked, ";Isnt it true if patient declines spiritual care or MSW (medical social worker), we are okay as long as we put in an order"? During an interview on 5/17/23, at 11:40 a.m., the OW stated Registered Nurse 1 (RN 1) was on vacation in Mikonos Greece. During an interview on 5/17/23 at 12:21 p.m., the OW stated accurate patient record keeping means: staff should write whatever is right for the patient, whatever they see they should document. Authentication means the staff write the note, the date they saw the patient, and electronically sign. During a record review on 5/17/23 at 12:29 p.m., P8s electronic record was reviewed. The review indicated there was no spiritual assessment documented. Further review of the record did not indicate a note or doctor order to explain why the spiritual assessment was not done. During an interview on 5/18/23 at 1:25 p.m., The OW stated RN 1 was on vacation in Greece. During an interview on 5/19/23 at 10:10 a.m., the IC stated she did not know where RN 1 was. During a concurrent interview and record review on 5/19/23 at 11:02 a.m., P8s record titled, ";Communication/Progress Log", dated 4/14/23, was reviewed with the DD. The record indicated, ";Communication ID 2975524, Event Date 4/14/2023...Comments Received report SC (Spiritual Care) services offered but declined. Will continue to be offered." The DD stated P8 had declined spiritual care services. During a concurrent interview and record review on 5/19/23 at 11:02 a.m., P8s record titled, ";Audit Log", dated 4/1/2023 to 5/19/2023, was reviewed with the DD. The record indicated, ";Modified Date 5/17/2023 7:40 a.m., Staff RN 1, Visit Date 4/14/23, Module ID 2975524.". The DD stated the audit log showed the communication note about denying spiritual services was added to P8s record on 5/17/23, around 7:40 a.m., by RN 1. 5). A review of P10 ";Personal Information" indicated a Start of Care date of 11/12/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During a concurrent interview and record review on 5/19/23 at 10:11 a.m. P10s record titled, ";Audit log", dated 4/1/2023 to 5/19/2023, was reviewed with the DD. The record indicated, ";Modified Date 5/17/23...Staff RN 1, Module Certification MD, Visit Date 5/11/2023, Field/Section: Physician Narrative: Certifying Physician Summary, Current Value Patient has been week, easily fatigued...I certify that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. Previous Value" nothing was recorded in this section. The DD stated the OW said RN 1 was on vacation. The DD stated the ";system keeps the log in information" and its possible the user did not log off and whoever used the computer used the saved log in information and logged in." During an interview on 5/19/23, at 1:26 a.m., the DD stated the document titled CTI (Certificate of Terminal Illness) the CTI needed to be signed by the doctor because the signature indicated the patient is certified for hospice care. The DD stated the doctor was expected to document on the physicians narrative area of the document. The DD stated none of the nurses at the agency document on the physicians narrative for the doctor. A review of P10s medical record titled ";Physicians Certification for Hospice Benefit, CTI", dated for 5/11/2023 to 7/9/2023, indicated, ";Medical Director Attestation/Certification: I attest/confirm that I composed this narrative based on my review of ...". Section ";Signature/Signature on file, Date" was blank. 6). A review of Patient 12 (P12) ";Personal Information" indicated a Start of Care date of 6/20/2022 with a primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified ang pectoris (coronary artery disease due to atherosclerosis is the buildup of fatty plaque along the walls of the arteries, which causes reduced blood flow to the hear causing chest pain.) During an interview on 5/18/23, at 12:15 p.m., the Medical Director 1 (MD 1) stated he documented his own findings in the medical record. MD 1 stated he made his own notes and transcribed it in the computer in their Electronic Medical Record (EMR). During a concurrent interview and record review on 5/19/23 at 2:37 p.m. P12s record titled, ";Audit log", dated 4/1/2023 to 5/19/2023, was reviewed with the OW. The record indicated, ";Modified Date 5/1/23...Staff OW, Module Certification MD, Visit Date 4/16/2023, Field/Section: Physician Narrative: Certifying Physician Summary, Current Value This is a ...with diagnosis of End Stage Heart Disease...". The OW stated it could be possible that the doctor logged into the computer at the office, because the OW does not log off and the doctor could have documented using the OWs username and password. A review of P12s medical record titled, ";Physicians Certification for Hospice Benefit CTI", for dates 4/16/2023 to 6/14/2023, indicated, ";Medical Director Attestation/Certification: I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment, and/or examination of the patient. Reviewed and electronically signed by" (MD 1), ";date 4/14/23". A review of P12s record titled, ";Audit log", dated 4/1/2023 to 5/19/2023, indicated ";Modified Date 5/17/23...Staff MD1, Module Certification MD, Visit Date 4/16/2023, Field/Section Signed, Current Value Reviewed and electronically signed by MD 1, Previous value Signature on File/Verified by" the OW. Further review of the record indicated, Modified Date 5/18/23...Staff MD1, Module Certification MD, Visit Date 6/20/2022, Field/Section Signed, Current Value Reviewed and electronically signed by MD 1, Previous value Signature on File/Verified by" the OW. A record review of the Hospice Agencys record titled, ";Computer Key/Password Statement", dated 7/29/19, indicated, ";I understand the need and responsibility to maintain a high level of security with computer access. I will not allow anyone to use my computer key/password and accept full responsibility for the security of my computer key/password." The record further indicated MD 1 singed the document on 7/29/19. A review of facilitys policy and procedure titled, ";Physician Services-Medical Director" revised April 2017, indicated ";The duties and responsibilities of the Medical Director will include... 3. Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with... interdisciplinary group... including written certification of terminal illness." A review of facilitys policy and procedure titled, ";Clinical Record Review" revised April 2017, indicated ";Clinical records will be reviewed at frequent intervals by the Clinical Director or designee to ensure that documentation is entered and is reliable, timely, valid, and accurate. D. No person involved in the care of a patient may participate in the review of that patients record." A review of facilitys policy and procedure titled, ";Medical Record Content" undated, indicated ";The Agency will initiate and maintained and individual and accurate medical record for each patient receiving care..." A review of facilitys policy and procedure titled, ";Medical Record Entries: Authentication" undated, indicated ";All entries in the medical records will be authenticated by staff by signing first name or initial, las name and title. By authenticating entries in the patients record, staff is validating the correctness of the information. If automated clinical record system is used, electronic signature authentication of entries will be in accordance with state law."

Based on interview and record review the Hospice Agency (HA) failed to ensure contents and information in the patients medical records were safeguarded from unauthorized access by unauthorized staff and contracted staff that could make alterations or modifications on the patients' medical records, four of 14 sampled patients (Patient 4, Patient10, Patient 11, and Patient 12). This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients clinical record that could affect the patients quality of care and well-being. --- 1). A review of Patient 4 (P4) ";Personal Information" indicated a Start of Care date of 3/1/2023 with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (the buildup of fatty material, called plaque, along the walls of the arteries.) A review of P4s record titled, ";Audit log" (a document that indicates the details of the changes made to a record), dated 4/1/2022 to 5/18/2023, indicated ";Modified Date: 5/12/2023..., Staff: Owner (OW), Module: Certification MD, Visit Date: 4/30/2023, Field/Section: Physician Narrative: Certifying Physician Summary, Current Value had documentation, Previous Value: was blank. Module ID: 1407823. 2). A review of P10 ";Personal Information" indicated a Start of Care date of 11/12/2022 with a primary diagnosis of Alzheimers disease (generalize degeneration of the brain). During an interview and record review on 5/19/23 at 10:10 a.m., P10s record titled, ";Audit Log", dated 4/1/2023 to 5/19/23, reviewed with the intake coordinator (IC). The record indicated, ";Modified Date 5/17/23...Staff Previous Employee (PE), Module Certification MD, Visit Date 11/12/2023, Field/Section RN Assessment Narrative...". The record further indicated, ";Modified Date 5/17/23...Staff Previous Employee (PE), Module Certification MD, Visit Date 11/12/2023, Field/Section Unlock." The IC stated she did not know who IC was. During an interview on 5/19/23 at 10:11 a.m., the Director of Patient Care Services Designee (DD) stated did not know who PE was. During an interview and record review on 5/19/23 at 2:29 p.m., P10s record titled, ";Audit Log", dated 4/1/2023 to 5/19/23, reviewed with the owner (OW). The OW stated the PE used to be the old administrator and director of nursing, back 7 to 8 years ago. The OW stated he asked her to log in to the records to take a look at them. The OW stated he did not ask her to change the patient records. The OW stated he pays the PE when she helps him. The OW stated the PE still has access to the patient records. 3). A review of P11's ";Personal Information" indicated a Start of Care date of 5/5/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). During an interview and record review on 5/18/23 at 1:35 p.m., P11s record titled, ";Audit Log", dated 4/1/2023 to 5/18/23, was reviewed with the intake coordinator (IC). The record indicated, ";Modified Date 5/17/23 1:02 p.m....Staff IC, Module Certification MD, Visit Date 4/20/2023, Field/Section RN Assessment Narrative, Current Value Recertified patient to..., Previous Value..." no record documented under this field. The IC stated she did not access in to P11s record to enter notes. The IC stated that was her name written in the audit log. The IC stated, she did not log off the computer until she went home. The IC stated she is not a licensed nurse. The IC stated she did not know who went into the record to document on P11s patient record. During a concurrent interview and record review on 5/18/23 at 1:35 p.m., P11s record titled, ";Audit Log", dated 4/1/2023 to 5/18/23, was reviewed with the DD. The record indicated, ";Modified Date 5/17/23 1:02 p.m....Staff IC..., The DD stated, she was present in the office on 5/17/23 at 1 p.m. and she did not access the record and/or enter notes. The DD stated she did not know who entered notes. During a concurrent interview and record review on 5/18/23 at 1:38 p.m., P11s record titled, ";Audit Log", dated 4/1/2023 to 5/18/23, was reviewed with the OW. The record indicated, ";Modified Date 5/17/23 1:02 p.m...., Staff IC..., The OW stated, ";gosh" they are supposed to log off when they are not using it, but none of us logs off; we stayed log in because its just us. During an interview on 5/19/23 at 2:42 p.m., the OW stated every staff has different levels of access to the electronic medical record. The OW stated his access overrides everyone elses. The OW stated the IC was an office manager, not a nurse. The OW stated the IC did not have any medical licenses or certificates. 4). A record review of P12 ";Personal Information" indicated a Start of Care date of 6/20/2022 with a primary diagnosis of Atherosclerotic heart disease of native coronary artery with unspecified ang pectoris (coronary artery disease due to atherosclerosis is the buildup of fatty plaque along the walls of the arteries, which causes reduced blood flow to the hear causing chest pain.) During an interview on 5/18/23 at 1:25 p.m., the OW stated Registered Nurse 1 (RN 1) was on vacation in Greece. The OW stated the DD had RN1s electronic access for Hospice MD. During an interview on 5/18/23, at 1:32 p.m., the DD stated she did not have RN 1s log in information for Hospice MD. During a concurrent interview and record review on 5/19/23 at 10:12 a.m., P12s record titled, ";Audit Log", dated 4/1/2023 to 5/19/23, was reviewed with the DD. The record indicated Registered Nurse 1 (RN 1) had modified P12s record on 5/17/2023, for ";Module Certification MD", for ";Visit Date 4/16/2023, 2/16/2023, 12/17/2023,10/18/2022 and 6/20/2022". When asked for an explanation, the DD stated the OW said RN 1 was on vacation. A review of facilitys policy and procedure titled, ";Clinical Record Review" revised April 2017, indicated ";Clinical records will be reviewed at frequent intervals by the Clinical Director or designee to ensure that documentation is entered and is reliable, timely, valid, and accurate. No person involved in the care of a patient may participate in the review of that patients record." A review of facilitys policy and procedure titled, ";Medical Record Entries: Authentication" undated, indicated ";All entries in the medical records will be authenticated by staff by signing first name or initial, last name and title. By authenticating entries in the patients record, staff is validating the correctness of the information. If automated clinical record system is used, electronic signature authentication of entries will be in accordance with state law." A review of facilitys policy and procedure titled, ";Computer Key/Password" undated, indicated ";At time of employment each individual who is authenticating medical record entries by computer will sign a statement that on one else will be allowed to use his/her computer key/password... The individual employee is responsible for maintaining the security of his/her computer key/password."

Based on interview and record review the Hospice Agency (HA) failed to notify the attending physician on the patient's discharged status due to death for one of 14 sampled patients (Patient 6). This deficient practice resulted in the patients attending physician not notified about the patients death and misinformation of medical healthcare information. --- 1). A review of Patient 6 (P6) ";Personal Information" indicated a Start of Care date of 12/3/2022 and a discharge date of 12/6/2022 with a primary diagnosis of Alzheimers Disease (generalize degeneration of the brain). It also indicated P6s Referring Doctor (MD 3). During an interview on 5/19 /2023 at 10:25 a.m. with the Director of Patient Care Services Designee (DD), DD stated, ";When patient is DC (discharged) I document and sign it at that time. They reported to me on 12/6/22. I get time and date of death and I document that. We always notify doctor and IDG of patients change of condition and death and discharge. Everybody needs to be on the same page, we need to know who we need to take care of. We notify MSW (medical social worker) and chaplain so they can call the patients and families and offer them help. A record review of P6s record titled, ";Audit log", dated 12/1/2022 to 5/19/2023, indicated ";Modified Date: 5/16/23...Staff: Registered Nurse (RN1), Module: Discharge, Visit Date: 4/16/2023, Field/Section: Txt Summary, Current Value: ";Copies of this discharge summary, CTI, medication lists, care plan will be sent to family and MD office", Previous value did not have the current statement. A review of facilitys policy and procedure titled, ";Discharge Summary" revised April 2017, indicated ";2. The discharge summary... will be completed and submitted within 72 hours of discharge from services. 3. A copy of the discharge summary will be provided to the patients attending physician." A review of facilitys policy and procedure titled, ";Medical Record Content" revised April 2017, indicated ";The Agency will initiate and maintained and individual and accurate medical record for each patient receiving care... Each medical record will contain the following: -Notification to the prescribing physician of patient discharge. -A discharge summary when patient is discharged from the Agency."

Based on record review and staff interview, the hospice agency failed to designate an interdisciplinary group (IDG, composed of individuals who provide or supervise the care and services offered by the hospice), in consultation with the patients physician and develop the patient's written plan of care (POC) for five of 8 sampled patients (PT1, PT2, PT3, PT7, and PT8). There was no documentation, the physician was consulted in the development of the plan of care, no the Social Services, and Chaplain, documentation of participation in preparing the POC. This deficient practice had a potential to prevent the patients from reaching their care goals. --- A review of Patient 7's Personal Information Sheet (Face Sheet) indicated a start of care (SOC) date of 7/7/22, with a primary diagnosis of heart failure, unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet tissue metabolic requirements)) without heart failure. A review of patient 7s Referral Information with a decision date of 4/26/22 and Expiration date of 9/23/22, indicated the Diagnosis of Unspecified Cirrhosis of Liver with request service for Palliative Care. A review of patient 7's "Physician's Certification Hospice Benefit'' for the second 90-day period, from 10/5//2022 to 1/2/2023, indicated, patient 7's terminal diagnose was Heart failure, unspecified) ( a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet tissue metabolic requirements)) without heart failure. There has no documented evidence the hospice agency's attending physician communicated with the patient's primary physician, to certify that patient 7 had a life expectancy of 6 months or less, "if the terminal illness runs it normal course." A review of the Patient 7s plan of care (POC) for the certification period of 10/5/22 to 1/2/23, instructed the skilled nurse (SN) to visit one time a week, the hospice aide to visit two times per week, the social worker to visit 1 time a month and the spiritual counselor to visit 1 time a month, A review of Patient 7s POC/IDG review dated 11/17/22 and 12/1/22, indicated there was no physician, medical social worker (MSW), Chaplain and Registered Nurse (RN) signature. A review of Patient 8s Face Sheet indicated a SOC of 11/18/21, with a diagnosis of chronic ischemic heart disease with heart failure (a heart problem caused by narrowed heart arteries which results in inadequate supply of blood to the heart). A review of Patient 8's Physician's Certification for Hospice Benefit (CIT), for the first 90 day period from 11/13/22 - 1/11/2, indicated that the medical doctor (MD) certified that Patient 7 has a life expectancy of six months or less, if the illness runs its normal course. A review of the Patient 8s plan of care (POC) for the certification period of 11/13/22 to 1/1/23, instructed the skilled nurse (SN) to visit one time a week, the hospice aide to visit two times per week, the social worker to visit 1 time a month and the spiritual counselor to visit 1 time a month, A review of Patient 8s POC/IDG review dated 11/17/22 and 12/1/22, indicated there was no physician, medical social worker (MSW), Chaplain and Registered Nurse (RN) signature. A review of PT 1s clinical record indicated PT 1 was admitted to the hospice agency (HA) on 7-7-22 with a primary diagnosis of Alzheimers Disease (a progressive neurodegenerative disease that develops gradually and is characterized by the destruction of nerve cells vital to memory and learning). A review of the PT 1's Plan of Care (POC) with a benefit period of 7/7/22 to 10/4/22 indicated Skilled Nurse visits 1 time per week, the Hospice Aide visits two times per week, the social worker visit 1 time per month, and the spiritual counselor visit 1 time per month. A review of PT 1s POC/IDG Review dated 11/17/22, indicated there were no physician's, MSW, Chaplain, and RN signatures for attendance for this period. A review of PT 1s POC/IDG Review dated 12/1/22 and 12/15/22 indicated there were no physicians, MSW, and Chaplain signatures for attendance for this period. On 12-27-22 at 2:45pm an interview was conducted in the agency conference room with RN1. RN1 stated it is my responsibility to ensure all IDG staff present in meetings to electronically sign the document and this was not done for the following dates, 11-17-22, 12-1-22, and 12-15-22. She further stated, in the medical field, all documentation should be signed and dated or its like it was never done. A review of PT 2s clinical record indicated PT 2 was admitted to the hospice agency (HA) on 3-25-22 with a primary diagnosis of hypertensive heart disease without heart failure (problem that occurs because of high blood pressure that is present over time) and a secondary diagnosis of angina pectoris (a condition marked by severe pain in the chest, often spreading to the shoulders, arms, and neck caused by an inadequate blood supply to the heart). A review of the Plan of Care with a benefit period from 3/25/22 to 6/22/22 indicated Skilled Nurse visit 1 time per week, hospice aide visit 1 time per week, spiritual counselor visit 1 time per month. A review of PT 2s POC/IDG Review dated 11/17/22, indicated there were no physician's, MSW, Chaplain, and RN signatures for attendance for this period. A review of PT 2s POC/IDG Review dated 12/1/22 and 12/15/22 indicated there were no physicians, MSW, and Chaplain signatures for attendance for this period A review of PI 3s clinical record indicated PT 3 was admitted to the hospice agency (HA) on 11/26/21 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (constriction of the airways and difficulty or discomfort in breathing) and a secondary diagnosis of acute renal failure (kidneys can no longer adequately filter waste products). A review of the Plan of Care with a benefit period from 11/26/21 to 2/23/22 indicated Skilled Nurse visit 1 time per week and spiritual counselor visit 1 time per month. A review of PT 3s POC/IDG Review dated 11/17/22, indicated there were no physician's, MSW, Chaplain, and RN signatures for attendance for this period. A review of PT 3s POC/IDG Review dated 12/1/22 and 12/15/22 indicated there were no physicians, MSW, and Chaplain signatures for attendance for this period. On 12/27/22 at 2:45 p.m., during an interview RN1 stated, "it is my responsibility to ensure all IDG staff present in meetings to electronically sign the document and this was not done for the following dates, 11/17/22, 12/1/22, and 12/15/22". She further stated, "in the medical field, all documentation should be signed and dated or its like it was never done." A review of the Agencys policy ";Interdisciplinary Group Coordination of care" with a revised date of April 2017 indicated the case manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge.

Based on observation, interview, and record review, the hospice agency (HA) failed to implement its Coronavirus 19 (COVID 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person) policy and procedures by failing to ensure the visitors were screened for signs and symptoms of COVID-19 including the temperature check.This deficient practice had a potential in placing the patients, staff, and visitors at risk for COVID-19 and further spread of infection that could lead to severe respiratory illness, hospitalization and/or death. --- During an observation on 12/27/22, at 11:00 a.m., at the hospice agency (HA), upon entrance to the HA, there was no screening for COVID-19 signs and symptoms and no temperature check. During an observation on 12/29/22, at 09:00 a.m., upon entrance to the HA, there was no screening for COVID-19 signs and symptoms and no temperature check conducted by the HA staff. During an interview on 12/30/22, at 12:50 p.m., the administrator/CEO stated, "No, we did not screen you for COVID symptoms. No, we did not take your temperature. We forgot. We are supposed to do it." The DPCS stated the HA should have a log to show the visitors were screened.

Based on record review and interview the facility failed to ensure that ordered counseling services were implemented and carried out for two of 8 sampled patients (PT1 and PT2). This deficient practice had a potential for the patient and family not to assist with their emotional needs that may arise from the terminal illness and dying process. --- a. A review of PT 1s clinical record indicated PT 1 was admitted to the hospice agency (HA) on 7/7/22 with a primary diagnosis of Alzheimers Disease (a progressive neurodegenerative disease that develops gradually and is characterized by the destruction of nerve cells vital to memory and learning). A review of the Plan of Care with a benefit period of 7-7-22 to 10-4-22 indicated Skilled Nurse visits 1 time per week, the Hospice Aide visits two times per week, the social worker visit 1 time per month, and the spiritual counselor visit 1 time per month. A review of the agencys electronic medical record for visits made indicated that ordered MSW visits of 1x/month was missing for Aug, Sept, and Nov of 2022 for PT 1. b. A review of PT 2s clinical record indicated PT 2 was admitted to the hospice agency (HA) on 3/25/22 with a primary diagnosis of hypertensive heart disease without heart failure (problem that occurs because of high blood pressure that is present over time) and a secondary diagnosis of angina pectoris (a condition marked by severe pain in the chest, often spreading to the shoulders, arms, and neck caused by an inadequate blood supply to the heart). A review of the Plan of Care with a benefit period from 3/25/22 to 6/22/22 indicated Skilled Nurse visit 1 time per week, hospice aide visit one time per week, spiritual counselor visit 1 time per month. A review of the agencys electronic medical record for visits made indicated that ordered MSW visits of 1x/month was missing for July, Aug, and Sept of 2022 for PT 2. On 12/27/22 at 2:45 p.m., during an interview RN1 stated, that MSW visits for these dates were missing and could not provide any additional information.

Based on interview and record review, the hospice agency failed to ensure that the governing body or the Administrator assumed full responsibility for the management, the provision of all hospice services, continuous quality assessment and performance improvement and appointed a qualified administrator to run the day to day operation of the hospice agency. This deficient practice had a potential for lack of service and poor management of day to day and services of hoepice agency. --- During an interview and record review on 12//27/22 at 2:45 p.m., the CEO stated, he was the administrator of the hospice agency and that the Administrator designee was on vacation, the director of patient care services designee (DPCS) worked full time at General Acute Care Hospital (GACH) and was not able to respond or answer her calls. During concurrent review with the CEO, of the patients clinical records stated, he did not know the process and could not answer questions regarding the patient's clinical record. On 12/30/22, review of the CEO/administrator employee files indicated he did not have the training to be the administrator. The CEO/administrator stated he took the training before COVID-19, however could not provide the survey team with documented proof he was qualified to be the administrator.

Based on record review and interview, the hospice agency failed to ensure that the governing body or the Administrator assumed full legal responsibility for the management, the provision of all hospice services, continuous quality assessment and performance improvement, and appointed a qualified administrator to run the day to day operation of the hospice. This deficient practice had a potential for HA, lack of quality of care and services provided to hospice patients and their family. --- On 12/30/22, at 10:45 a.m., during an interview with the Administrator/CEO, he stated he could not assist the survey team with answering any questions regarding the patients clinical record or care provided. The administrator/CEO stated the administrator designee was on vacation and the DPCS designee worked full time at a general acute care hospital (GACH) and was not answering calls/texts. The Administrator stated the agency had not conducted an interdisciplinary group meeting, there was no COVID 19 vaccination program developed and implemented for all the agency's staff.Review of the hospice agency's job description of Executive Director/Administrator dated 11/2017, stipulates, "The Executive Director/Administrator is responsible for the overall direction of the day to day operations of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy."

Based on interview and record review, the hospice agency f(HA) ailed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness for two of 12 sampled patients. This deficient practice had a potential to result in lack of quality of care and services provided to meet the patients care and services needs. --- A review of Patient 7's Personal Information Sheet (Face Sheet) indicated a start of care (SOC) date of 7/7/22, with a primary diagnosis of heart failure, unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet tissue metabolic requirements) without heart failure. A review of patient 7s Referral Information with a decision date of 4/26/22 and expiration date of 9/23/22, indicated the diagnosis of unspecified Cirrhosis of Liver with request service for Palliative Care. A review of patient 7's "Physician's Certification Hospice Benefit'' for the second 90-day period, from 10/5//2022 to 1/2/2023, indicated, patient 7's terminal diagnose was Heart failure, unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet tissue metabolic requirements)) without heart failure. There was no documentation, the hospice agency's attending physician communicated with the patient's primary physician, to certify that patient 7 had a life expectancy of 6 months or less, "if the terminal illness runs it normal course." A review of Patient 7's Comprehensive Nursing Assessment, dated 7/7/22, under the section "Nature and Condition of Terminal Illness/LCD Eligibility", indicated that Patient 7's terminal illness of heart disease was reported by the patient and patient caregiver/family, no medical history was documented. A review of Patient 7's Local Coverage Determination (LCD)Hospice Eligibility Determination sheet, (undated), under NYHA classification is ejection fraction < 20 was blank and that Patient 7 had a history of unexplained fainting. There was no documentation found in Patient 7's medical record to support the patient's history of unexplained fainting. A review of Patient 8's Face Sheet indicated a SOC of 11/18/21, with a diagnosis of chronic ischemic heart disease with heart failure (a heart problem caused by narrowed heart arteries which results in inadequate supply of blood to the heart). A review of Patient 8's Comprehensive Nursing Assessment, dated 11/18/21, under the section "Nature and Condition of Terminal Illness/LCD Eligibility", indicated that Patient8's terminal illness of heart disease was reported by medical history, the patient and family, no medical history was used as evidence. It also stated that Patient 8 had two ER visits or hospitalizations in the last 12 months. Patient 8 needs assistance with walking, toileting, transfers, dressing, feeding, or bathing. A review of Patient 8's Physician's Certification for Hospice Benefit (CIT), for the first 90 day period from 11/13/22-1/11/2, indicated that the medical doctor (MD) certified that Patient 8 has a life expectancy of six months or less, if the illness runs its normal course. There were three option below for certification of the patient, 1. Medical history, record and patient status 2. Team Assessment 3. Face to face encounter The CTI indicated it was based off of medical history, record and patient status, team assessment. There was no physician narrative note indicating that a face-to-face visit was conducted. A review of Patient 8's Local Coverage Determination (LCD) Hospice Eligibility Determination sheet, (undated), indicated that Patient 8 has a history of an ejection fraction of < 20, treatment-resistant symptomatic supraventricular or ventricular arrhythmias, a history of cardiac arrest/resuscitation, unexplained fainting, and any brain embolism of cardiac origin. Although, there was no documentation found in Patient 8's medical record to support the stated history. A review of Patient 8's "Physician's Certification for Hospice Benefit" for the tenth 60- day recertification period from 7/10/2022 to 9/7/2022, indicated Patient 8's hypertensive heart disease without heart failure. There was no documented evidence the hospice agency's medical director or the hospice attending physician had communicated with the patient's primary physician to certify that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course." A review Patient 8's "Initial Nursing Assessment" visit by the RN, dated 11/17/2020, indicated Patient 8 was alert, requires bed/wheelchair bound and requires maximum assistance , with standing, requires oxygen at 2 liters per minute (LPM) as needed, with activities up as tolerated/ On 12/30/22 at 2:02 p.m., during a telephone interview with the hospice agency's Medical Doctor (MD) in the conference room of the hospice agency regarding determining hospice criteria, he stated he reviewed the supporting evidence to determine hospice from records from the admitting Registered Nurse (RN). The Hospice agency's MD conducts a face-to-face visit and based on the documentation from the skilled nurse assessment in the patients chart and his assessment, qualifies the patients for hospice. The hospice agency's MD stated, he has not viewed the hospital, records from primary doctors, labs, diagnostic records, reviews the chart and that maybe they need to incorporate that procedure, before admitting the patients to hospice. The MD stated, he thought the staff notified the patient's primary physician. During an interview and concurrent patient record review with the CEO and DPCS in the hospice agency's conference room on 12/30/2022, at 3:30 p.m., regarding determining hospice criteria, the CEO stated, he did not know and could not answer the question. The administrator/CEO stated, the administrator designee and DPCS designees responsibility however one was on vacation and the other one cannot be reached due to working at a general acute care facility and not responding to phone calls and texts at this time. The administrator/CEO was unable to provide the surveyor with all supporting evidence, such as labs, records from the primary doctor, diagnostic results. A review of the hospice agency's policy and procedure on " Admission Criteria and process revised April 2018, stipulates, " Referral information provide by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician office will assist in the determination of eligibility for admission to the program. If the request for services is not made by the patient's physician, he/she will be consulted prior to the evaluation visit/initiation of services."

Observed in Record Review. In 1 of 11 patient records reviewed, During HV#3 record review it was noted the patient acknowledgment form used during the admission process to summarize the information the patient received was signed by the patient representative but was blank. The acknowledgment check list included but not limited to information on rights, responsibilities, visit frequency, and services to be provided. This was discussed with the Administrator and DPCS designee.

Observed in Record Review. In 9 of 11 patient records reviewed, During HV#1-3 record reviews and RR#2-7 it was noted the Spiritual Counselor (SC) and the MSW did not update the comprehensive assessment during IDG meetings. The documentation was identical for the records reviewed at each IDG by the SC and the MSW. In addition during RR#5 it was also noted the end of April 2022, the patient's daughter refused the SC visit and stated spiritual counselor was not needed at this time. This information was not updated at the IDG 2 days later. During RR#2 and #3 there was sporadic documentation reflective of the findings documented during visits by the SC and MSW at IDG meetings. This was discussed with the Administrator and DPCS designee.

Observed in Record Review. In 1 of 11 patient records reviewed, During HV#2 record review it was noted during the July 2022 recertification assessment the MSW documented information that was not accurate. The MSW documentation stated the patient was a full code and had not made mortuary arrangements. The record contained a POLST form that stated the choice of a DNR status during admission. The record also contained the name of the mortuary the patient/family had chosen. This was discussed with the DPCS designee with correction addendum to the medical record by the MSW.

Observed in Record Review. In 1 of 11 patient records reviewed, During RR#7 it was noted an order for skin care around a urostomy tube was not added to the POC to identify the problem, establish interventions and goals. This was discussed with the Administrator and DPCS designee.

Observed in Record Review. In 2 of 11 patient records reviewed, Care and services were not provided in accordance with the POC. During RR#7 it was noted an order for the hospice aide 2x/week. A comm note stated the aide could not provide care to the patient and another aide would be assigned. There was lack of documentation of hospice aide visits since the initial assignment form completed by the RN. The aide visits were discontinued by the IDG 17 days later when continuous care was initiated. During RR#7 It was noted an order for skin care/dressing changes around a urostomy tube were not performed as ordered. An order written 2 days after the initial RN assessment for urostomy care was cleanse stoma site with normal saline and pat dry. Replace wafer once a month and as needed for displacement. Change urostomy bag once a week or as needed for leakage. An update to the order 6 days later was to cleanse skin around catheter with warm water, pat dry, apply triple antibiotic around catheter insertion site, cover with split gauze, secure with tape. Change dressing every 3 days and as needed for soiling or loss of integrity'. The MR lacked documentation of dressing changes and description of the skin around the urostomy tube insertion site until 14 days later during continuous care by SN. During RR#3 it was noted an order on the POC for wound care to a lower extremity dermatitis stasis venous issue as follows: Cleanse with normal saline solution, pat dry, apply Hydrocortisone Ointment 1%, cover with dry dressing and secure with tape once a day for 30 days. PCG to perform wound care on non nursing visit days. The wound care was documented as completed by the SN on 2 of 4 visits in October-middle of November 2021. This was discussed with the Administrator and DPCS designee. This was discussed with the Administrator and DPCS designee.