Every finding on record at A1 Palliative and Hospice Care, Inc

Based on interview and record review the hospice agency (HA) failed to ensure coordination of care and services was carried out between interdisciplinary team. The agency failed to ensure that laboratory orders written in a face to face note by a medical practitioner, was added to the patients treatment plan and carried out for one of seven sampled patients (Patient 15). This deficient practice resulted in Patient 15 did not have laboratory test as ordered and could caused for Patient 15 not to received the appropriate care needed. --- A review of Patient 15s Personal Information Sheet (face sheet) indicated Patient 15's start of care (SOC) date was 12/18/2023, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of hypertensive heart disease without heart failure (condition where high blood pressure damages the heart muscle, but not to the point were the heart stops pumping blood effectively). Patient 15 did not have secondary diagnoses listed on the face sheet. A review of Patient 15's Face to Face Narrative note, dated 11/24/2023, indicated that the Nurse Practitioner (NP1) narrative note that Patient 15 needed laboratory work (blood samples) for Complete Blood Count) (CBC, a common blood test that measures the number and types of various cells in the blood), basic metabolic panel (BMP, a group of blood tests that measures several key substances in the body), fasting lipid profile (a blood test that measures the levels of fat in your blood after you've gone without eating or drinking anything but water for 8 to 12 hours), A1C (a diabetes test), and fasting glucose (sugar in the blood). A review of Patient 15's Face to Face Narrative note, dated 4/26/2024, indicated NP1's narrative note that the Patient 15 needs the following laboratory CBC, Sodium (NA, a mineral in the body that is needed to function properly), K (potassium-mineral), CL (chloride-mineral), CO2 (carbon dioxide), and A1C. A review of Patient 15's Current Treatment Orders did not indicate any orders for laboratory work/test. A review of the HA's electronic charting system did not indicate Patient 15 had any laboratory work/test results uploaded to the system. During an interview on 1/31/2025, at 1:15 pm, Patient 15 stated that no one ever came to his home to take a blood sample. Patient 15 stated that the only time he gets his blood drawn is when he sees him primary physician. During an interview on 1/31/2025, at 3:28 pm, with the Director of Nursing (DON), the DON stated NP1 wrote laboratory orders to get baseline blood levels for Patient 15, but laboratory test were never done. The DON stated that she should have followed up to make sure the order was carried out. The DON stated that it is important for the Patient 15 to get the laboratory work/test done because it would have given them baseline blood levels for Patient15 and other patients (in general), that way they could see if there were any abnormalities which would guide them to provide the proper treatment for the patient (in general). A review of the HA's policy titled, "Verification of Physician Orders", dated 4/2020, indicated the following.. Orders will be obtained from a licensed physician (or other authorized independent practitioner) for care and services to be provided to hospice patients. A qualified individual will review each order or prescription before care is provided. The sole exception for verification will be with emergency orders or prescriptions where a delay for verification would likely result in an adverse result for the patient.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that the geographical service area (refers to the specific region where a service provider operates and delivers services) was approved by the California Department of Public Health (CDPH) for one of seven sampled patients (Patient 19). This deficient practice had the potential to place Patient 19 at risk for inadequate supervision of care. --- Findings: During a review of Patient 19's clinical record indicated a start of care date (SOC) of 11/04/2024, with a diagnosis of senile degeneration of brain (decline in an individual's memory, behavior, and cognitive abilities). Further review of Patient 19s clinical record indicated Patient 19 lived in San Diego, California. During an interview on 1/31/2025, at 2:10 p.m., and at 2:38 p.m., with the Office staff (OS), the OS stated the HA geographical service area was all of California. The OS stated the HA agency had a fire around 2017 and was unable to provide documentation that the HA's geographical service area was all of California. The OS stated the last time HA followed up with the District Office (DO) regarding geographical service area was on 9/2023 and the DO responded indicating ";our office has no record of requested documents". During an interview on 1/31/2025, at 2:43 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated that the records regarding the HA geographical service area being all of California was lost during a fire, and they would follow-up with the appropriate agency regarding geographical service area. Policy and procedure for geographical service area was requested and the agency did not provide.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the licensed staff (in general) accurately documented clinical notes for one of seven sampled patients (Patient 19). The deficient practice resulted in Patient 19 having inaccurate clinical records that could affect the patient's care. --- Findings: During a review of Patient 19's admission record indicated a start of care date (SOC) of 11/04/2024, with a diagnosis of senile degeneration of brain (decline in an individual's memory, behavior, and cognitive abilities). During a review of Patient 19s Physicians Certification for Hospice Benefit Certification number one, dated 11/04/2024, the Physician's Certification for Hospice Benefit Certification indicated that patient was a full code (medical personal would do everything possible to save your life in a medical emergency). During a review of Patient 19s Physician Order for Life-Sustaining Treatment (POLST), dated, 10/27/2024, the POLST indicated ";Do not attempt resuscitation (revive someone from apparent death)." During an interview on 1/31/2025, at 2:43 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated the POLST and the CTI (Certification of Terminal Illness) should match. The DPCS stated that it was important for the POLST and CTI to match so that the team would know what needs to be done in the event of an emergency. During a review of the agencys policy and procedure titled ";Content of Clinical Records," revised 04/2008, indicated that the clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel.

Based on interview and record review, the Hospice (specialized care provided to terminally ill [patients who have six months or less to live] patients) Agency (HA, agency providing care to terminally ill patients ) failed to ensure the Condition of participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) failed to ensure the Condition of participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) regarding Initial (of, at, or concerning the beginning) and Comprehensive assessments (an assessment used to evaluate a patient's overall health, including identifying the patients need for hospice care) were met as follows by failing to: --- 1. Failing to ensure that licensed nurses (in general) assessed all body systems, psychosocial and spiritual needs of Patient 1, for certification period 2/5/2024 to 5/4/2024, 5/5/2024 to 8/2/2024, 8/3/2024 to 10/1/2024, and 10/2/2024 to 11/30/2024. Patient 1s start of care (SOC) was on 2/5/2024. 2.Failing to ensure that licensed nurses (in general) assessed all body systems, psychosocial and spiritual needs of Patient 9, for certification period 8/27/2024 to 10/25/2024 and 10/26/2024 to 12/24/2024. Patient 9s SOC was on 12/31/2023. The non-compliance resulted in the HA providing care to Patient 1 and Patient 9 without assessing and identifying the hospice needs for Patient 1 and Patient 9 that could result to missed clinical interventions to provide high quality end of life care. (Refer to L524). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (written law) compliance with Federal Regulations for Initial and Comprehensive assessment of the patient, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive Medicare hospice benefits. 1. The HA failed to conduct and document an initial assessment identifying the need for hospice care and services for one of fourteen sample selected patients (Patient 1). This failure resulted in the HA not knowing what Patient 1s physical, psychosocial, emotional, or spiritual care needs were. (Refer to L 522). 2. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after hospice election for two of fourteen sample selected patients (Patient 1 and Patient 11). (Refer to L 523). 1. The HA failed to ensure: a. licensed nurses (in general) assessed all body systems, psychosocial and spiritual needs of Patient 1, for certification period 2/5/2024 to 5/4/2024, 5/5/2024 to 8/2/2024, 8/3/2024 to 10/1/2024, and 10/2/2024 to 11/30/2024. Patient 1s start of care (SOC) was on 2/5/2024. b. Failing to ensure that licensed nurses (in general) assessed all body systems, psychosocial and spiritual needs of Patient 9, for certification period 8/27/2024 to 10/25/2024 and 10/26/2024 to 12/24/2024. Patient 9s SOC was on 12/31/2023. The non-compliance resulted in the HA providing care to Patient 1 and Patient 9 without assessing and identifying the hospice needs for Patient 1 and Patient 9 that could result to missed clinical interventions to provide high quality end of life care. (Refer to L524). 2. The HA failed to review all medications the patients were taking and update their medication profiles with the currently used medications for two of fourteen sample selected patients (Patient 2 and Patient 13). The patients were at risk for medication errors and adverse drug reactions. (Refer to L 530). 3. The HA failed to conduct an initial bereavement assessment to provide bereavement counseling in accordance with the patient/family's needs for two of fourteen sample selected patients (Patient 3 and Patient 11) 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). 4. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for eight of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 11, Patient 13 and Patient 14). (Refer to L 533). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (written law) compliance with Federal Regulations for Initial and Comprehensive assessment of the patient, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive Medicare hospice benefits.

Based on interview and record review, the Hospice Agency (HA) failed to conduct and document an initial assessment identifying the need for hospice care and services for one of fourteen sample selected patients (Patient 1). This failure resulted in the HA not knowing what Patient 1s physical, psychosocial, emotional, or spiritual care needs were. --- During an interview on 10/31/2024 at 12:30 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated patient assessments are critical. The DPCS stated that a patients initial and comprehensive assessments should be completed within 24-48 hours of the start of care. The DPCS stated that during the initial and comprehensive assessment the patients are provided with the explanations of benefits, and educated on the HAs philosophy. The DPCS stated patients are assessed and reassessed to make sure they qualify for hospice services. During an interview on 10/31/2024 at 2:45 p.m. with the HAs Electronic Medical Record (EMR) systems representative (RP1), the RP1 stated that a red ";X" under the status column indicates that a visit has been created but it has not been submitted for review to the QA (quality assurance) staff. During a record review of Patient 1s medical record form titled ";Personal Information" the Personal Information record indicated a start of care date of 2/5/2024 with a primary diagnosis of chronic obstructive pulmonary disease (difficulty breathing cause by several lung issues). During a record review of Patient 1s medical record form title ";History of Nursing Assessment" dated 2/5/2024, 4/15/2024, 4/29/2024, 6/10/2024, and 6/24/2024, had a red ";X" under status. During a record review of Patient 1s medical record form title ";Comprehensive Nursing Assessment" dated 2/5/2024, indicated section ";Body System (Head-to-toe)" assessment sections were left blank. The form also indicated sections: ";Imminently Dying, Environmental/Safety, Personal Care and Support Needs, Teaching Needs, Psychosocial Screening, Spiritual Screening, Bereavement Screening, and Referrals were left blank. Lastly the form does not indicate who the author was. During a concurrent interview and record review on 11/1/2024 at 2:42 p.m. with the DPCS of Patient 1s EMR, medical record form titled ";Comprehensive Nursing assessment" dated 2/5/2024, the DPCS stated Patient 1s comprehensive assessment was missing a head-to-toe assessment, therefore, it was not complete. The DPCS stated the nursing assessments are important because the patient needs are based on it. The DPCS stated the patient had the potential to miss out on interventions or treatments needed. The DPCS stated Patient 1s assessments are missing the baseline, which is key to his care. During a record review of the HAs form titled ";Contents of Clinical Record" revised 4/2020, the form indicated, ";The clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. The following information will be available in the clinical record as applicable to care and services provided: C. Patient and family/caregiver initial, comprehensive, and ongoing comprehensive assessments. Each entry will be dated and signed, including title and credentials, by the person providing the care/service. During a record review of the HAs form titled ";Admission Criteria and Process" revised 4/2020, the form indicated, ";The Clinical Supervisor/Nursing Supervisor will assign hospice personnel to conduct initial assessments of eligibility for services within 24 hours... During the initial assessment visit, the admitting clinician will assess the patients eligibility for hospice services..." During a record review of the HAs form titled ";Initial Assessment" revised 4/2020, the form indicated, ";An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care. The initial assessment will be filed in the patients clinical record."

Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) completed the comprehensive assessment no later than five (5) calendar days after hospice election for two of fourteen sample selected patients (Patient 1 and Patient 11). This failure had the potential to result in patients not receiving appropriate healthcare services that could affect their quality of life. --- During a record review of Patient 1s medical record form titled ";Personal Information," the Personal Information Record indicated a start of care date of 2/5/2024 with a primary diagnosis of chronic obstructive pulmonary disease (difficulty breathing caused by several lung issues). During a record review of Patient 1s medical record form title ";Comprehensive Nursing Assessment" dated 2/5/2024, the assessment indicated the section for ";Body System (Head-to-toe)" assessment were left blank. The form also indicated the sections for ";Imminently Dying, Environmental/Safety, Personal Care and Support Needs, Teaching Needs, Psychosocial Screening, Spiritual Screening, Bereavement Screening, and Referrals were left blank. Lastly the form did not indicate who the author was. During a record review of Patient 1s medical record form title ";History of Nursing Assessment" dated 2/5/2024, 4/15/2024, 4/29/2024, 6/10/2024, and 6/24/2024, had a red ";X" under status. During an interview on 10/31/2024 at 12:30 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated patients assessments are critical. The DPCS stated that a patients initial and comprehensive assessments should be completed within 24-48 hours of start of care. The DPCS stated that during the initial and comprehensive assessment the patients are provided with the explanations of benefits and educated on the HAs philosophy. The DPCS stated patients are assessed and reassessed to make sure they qualify for hospice services. During an interview on 10/31/2024 at 2:45 p.m. with the HAs Electronic Medical Record (EMR) systems representative (RP1), the RP1 stated that a red ";X" under the status column indicated that a visit has been created but it has not been submitted for review to the QA (quality assurance) staff. During a concurrent interview and record review on 11/1/2024 at 2:42 p.m. with the DPCS of Patient 1s EMR, medical record form titled ";Comprehensive Nursing assessment" dated 2/5/2024, the DPCS stated Patient 1s comprehensive assessment was missing a head-to-toe assessment, therefore, it was not complete. The DPCS stated the nursing assessments are important because the patients needs are based on it. The DPCS stated the patient had the potential to miss out on interventions or treatments needed. The DPCS stated Patient 1s assessments are missing the baseline, which is key to his care. During a record review of the HAs form titled ";Contents of Clinical Record" revised 4/2020, the form indicated, ";The clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. The following information will be available in the clinical record as applicable to care and services provided: C. Patient and family/caregiver initial, comprehensive, and ongoing comprehensive assessments. Each entry will be dated and signed, including title and credentials, by the person providing the care/service. During a record review of the HAs form titled ";Admission Criteria and Process" revised 4/2020, the form indicated, ";The Clinical Supervisor/Nursing Supervisor will assign hospice personnel to conduct initial assessments of eligibility for services within 24 hours... During the initial assessment visit, the admitting clinician will assess the patients eligibility for hospice services..." During a record review of the HAs form titled ";Initial Assessment" revised 4/2020, the form indicated, ";An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care. The initial assessment will be filed in the patients clinical record."

Based on interview, and record review, the Hospice (specialized care provided to terminally ill [patients who have six months or less to live] patients) Agency (HA, agency providing care to terminally ill patients) failed to ensure the comprehensive assessments (an assessment used to evaluate a patient's overall health, including identifying the patients need for hospice care) were done for two of fourteen sampled patients (Patient 1 and Patient 9) by failing to: 1. Ensure that (licensed nurses in general) assessed all body systems, psychosocial and spiritual needs of Patient 1, for the certification period 2/5/2024 to 5/4/2024, 5/5/2024 to 8/2/2024, 8/3/2024 to 10/1/2024, and 10/2/2024 to 11/30/2024. Patient 1s start of care (SOC) was on 2/5/2024. 2. Ensure that the licensed nurses (in general) assessed all body systems, psychosocial and spiritual needs of Patient 9, for certification period 8/27/2024 to 10/25/2024 and 10/26/2024 to 12/24/2024. Patient 9s SOC was on 12/31/2023. The non-compliance resulted in the HA providing care to Patient 1 and Patient 9 without assessing and identifying the hospice needs of Patient 1 and Patient 9 that could result in missed clinical interventions to provide high quality end of life care. On 11/1/2024, at 4:45 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient), in the presence of the agencys Director of Patient Care Services (DPCS), related to the failure to ensure the comprehensive assessments were complete for two of fourteen sampled patients (Patient 1 and Patient 9), which resulted in the Hospice Agency providing care without assessing and identifying the needs of Patient 1 and Patient 9 that could result to hospitalization and death. On 11/2/2024, at 1:45 pm, the Survey team completed the survey tasks and conducted an exit conference with the DPCS, Office manager, and the Quality Assurance nurse with the IJ situation not removed. The HA did not submit an IJ removal plan. --- Findings: 1. During a review of Patient 1s Personal Information sheet, the Personal Information sheet indicated a SOC date of 2/5/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-difficulty breathing cause by several lung issues). During a review of Patient 1s undated History of Nursing Assessment, the History of Nursing Assessment indicated there were five entries made dated 2/5/2024, 4/15/2024, 4/29/2024, 6/10/2024 and 6/24/2024, with a red ";X" (the visit was scheduled and not conducted) under each dates status indicating.... During a review of Patient 1s Comprehensive Nursing Assessment, dated 2/5/2024, the Comprehensive Nursing Assessment indicated section ";Body System (Head-to-toe [a comprehensive physical examination that evaluates a patient's overall health status, needs, and goals)" assessment sections were blank. The Comprehensive Nursing Assessment indicated sections: ";Imminently Dying, Environmental/Safety, Personal Care and Support Needs, Teaching Needs, Psychosocial Screening, Spiritual Screening, Bereavement Screening, and Referrals were blank and did not indicate who the author was. During a review of Patient 1s undated History of Visit Notes, the History of Visit Note indicated six entries dated 3/13/2024, 3/27/2024, 4/13/2024, 4/27/2024, 5/11/2024, and 5/25/2024 with a red ";X" on their status. During a review of Patient 1s History of Plan of Care (POC-a patients assessed health or care needs ) and Interdisciplinary Group (IDG- a group of health care professionals with various areas of expertise who work together toward the goals of their patients), the History of POC and IDG indicated Patient 1s last interdisciplinary meeting was held on 4/5/2024. During a review of Patient 1s Visit Note LVN (License Vocational Nurse), dated 4/13/2024, Visit Note LVN indicated form was blank. During a review of Patient 1s Updated Assessment dated 4/15/2024, the Updated Assessment indicated the form was blank. During a review of Patient 1s Visit Note LVN dated 4/27/2024, the Visit Note LVN indicated the form was blank. During a review of Patient 1s Updated Assessment dated 4/29/2024, the Updated Assessment indicated the form was blank. During a review of Patient 1s Visit Note LVN dated 5/11/2024, the Visit Note LVN did not indicate who the author was. During a review of Patient 1s Updated Assessment dated 6/10/2024, the Updated Assessment indicated the form was blank. During a review of Patient 1s Updated Assessment dated 6/24/2024, the Updated Assessment indicated the form was blank. During a review of Patient 1s POC Summary dated as of 10/29/2024, the POC Summary indicated the section for allergies, functional limitation Activities of Daily Living (ADL- bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) need, mental status, disaster triage (the process of prioritizing patients for treatment), and treatment were left blank. During an interview on 10/31/2024 at 2:45 p.m. with the HAs Electronic Medical Record (EMR) systems representative (RP1), RP1 stated that a red ";X" under the status column indicates that a visit has been created but it has not been submitted for review to the QA (quality assurance) staff. An attempt to contact Patient 1 was made on 11/1/2024, at 1:42 pm, without success. An attempt to contact Patient 1s Family Member (FAM1) was made on 11/1/2024, at 1:43 pm without success. During a concurrent interview and record review on 11/1/2024, at 2:42 p.m. with the DPCS, reviewed Patient 1s Comprehensive assessment, dated 2/5/2024. The DPCS stated Patient 1s Comprehensive Assessment was missing a head-to-toe assessment, psychosocial screening, spiritual screening, bereavement screening were not complete. The DPCS stated Patient 1s Comprehensive Assessment was also missing the authors name and signature. The DPCS stated the nursing assessments were important because the patient needs were based on the assessment. The DPCS stated Patient 1 had the potential to miss out on interventions or treatments needed. The DPCS stated Patient 1s assessments were missing Patient 1s ";baseline," (medical condition at the time of admission), which was ";key," (important) to Patient 1s care. During an interview on 11/1/2024, at 2:42 pm, with the Director of Patient Care Services (DPCS), the DPCS stated she did not know the reason why the comprehensive assessment was not done for Patient 1. During a concurrent interview and record review on 11/1/2024, at 2:55 p.m., with the DPCS, reviewed Patient 1s undated POC Summary dated as of 10/29/2024. The DPCS stated the POC (plan of care) Summary was not complete. The DPCS stated that Patient 1s POC Summary should have been completed by the HAs Registered Nurse (RN).The DPCS stated that there was no comprehensive assessment done for Patient 1. The DPCS stated it was impossible to formulate Patient 1s POC without an RN assessment. 2. During a review of Patient 9s Personal Information sheet, the Personal Information sheet indicated a SOC date of 12/31/2023 with a primary diagnosis of hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 9s Updated Assessment (an assessment of the patients current status), dated 8/8/2024, the Updated Assessment indicated the form was blank. During a review of Patient 9s Updated Assessment, dated 8/22/2024, the Updated Assessment indicated the form was blank. During a review of Patient 9s Re-Cert Assessment, (recertification assessment), dated 8/22/2024, the Re-Cert indicated that section ";Body System (Head-to-toe)" assessment sections were blank. Body System (Head-to-toe [a comprehensive physical examination that evaluates a patient's overall health status, needs, and goals)" assessment sections were blank. The Comprehensive Nursing Assessment indicated sections: ";Imminently Dying, Environmental/Safety, Personal Care and Support Needs, Teaching Needs, Psychosocial Screening, Spiritual Screening, Bereavement Screening, and Referrals were blank and did not indicate who the author was. During a review of Patient 9s Updated Assessment, dated 9/5/2024, the Updated Assessment, indicated the form was blank. During a record review of Patient 9s Updated Assessment, dated 09/19/2024, the Updated Assessment indicated the form was blank. During an interview on 10/31/2024, at 1:40 pm with RN2 regarding Patient 9s Updated Assessments dated 8/8/2024, 8/22/2024, 9/5/2024, and 9/19/2024, RN2 did not have any information. During an interview on 11/1/2024, at 3:05 pm with the DPCS, the DPCS stated Patient 9s Updated Assessments dated 8/8/2024, 8/22/2024, 9/5/2024, and 9/19/2024, there were not complete including: environmental, mobility, intravenous (IV, under the vein) assessments for each date provided. The DPCS stated she (DPCS) is responsible to check all the patients charts and to ensure the updated assessments were complete which were not done. During an interview on 10/31/2024, at 12:30 p.m., with the DPCS, the DPCS stated the patient assessments were critical. The DPCS stated that the patients (in general) initial and comprehensive assessments should be completed within 24 to 48 hours of SOC. The DPCS stated during the initial and comprehensive assessment, the patients were provided with the explanations of the hospice benefits, and education on the HAs philosophy. The DPCS stated patients are to receive a nursing recertification assessment 90 days from the SOC, and every 60 days after that. The DPCS stated patients need to be assessed and reassessed to make sure they (patients) qualify for hospice services. During an interview on 10/31/2024, at 1:15 p.m., with the DPCS, the DPCS stated hospice was holistic (whole) and included spiritual services. During an interview on 10/31/2024, at 1:20 p.m., with the DPCS, the DPCS stated psychosocial assessments were important to address the patients psychosocial needs. The DPCS stated some of the needs included dealing with family dynamics, family support, home support and meals on wheels. The DPCS stated a psychosocial assessment needed to be done within five days to assess the needs and psychosocial needs of the patient. The DPCS stated the psychosocial assessment was very important because the patients have psychosocial needs. During an interview on 10/31/2024, at 1:25 p.m., with the DPCS, the DPCS stated a patients individualized plan of care served as a guide for visiting nurses. During an interview on 10/31/2024, at 1:35 p.m., with the DPCS, the DPCS stated skilled nurses (SN, in general) were expected to document 24 to 48 hours after a patients home visit. The DPCS stated nursing visit documentation were important because they serve as proof of their visits and services provided. The DPCS stated the nurses visit notes also serve as communication and collaboration among the team. The DPCS stated the initial bereavement assessment was important to know the spiritual needs of the patient and family. The DPCS stated the initial assessment should be completed within five days of start of care. The family needs to be assessed to prepare them for the expected decline of the patient. And it is an emotional aspect of life, no matter the age as a human being they need dignity. Sometimes there are unresolved conflicts, and they can pour out their hearts, sometimes the family have resentments. They need to have an ear to hear them, it is very difficult. During an interview on 10/31/2024, at 2:30 p.m., with the DPCS, the DPCS stated the red x means the assessments including (initial assessment, updated assessment, comprehensive assessment) has not been completed yet. The DPCS stated the nursing notes attest that they (nurses) saw the patient and that they (nurses) assessed the patient. The DPCS stated based on the assessment if the notes were not there the DPCS could not see the current status of the patient or his interventions. The DPCS stated Patient 1 might not get the care that the patient needs. The DPCS stated she knew if the nurses (in general) did not document, they (the nurses) did not visit. The DPCS stated if the nurses did not document the initial assessment, updated assessment, comprehensive assessment were not documented, it meant that the assessments were not done, and the documentation was proof the assessments were done. During an interview on 11/1/2024, at 3:05 pm, with the DPCS, the DPCS stated she did not know the reason why the comprehensive assessment was not done for Patient 9. During a review of the HAs Initial Assessment policy, dated April 2020, the Initial Assessment policy indicated that an initial assessment will be performed by a registered nurse within 48 hours after election of hospice care unless otherwise specified by the physician, patient or representative to be completed in less than 48 hours. During a review of the HAs Comprehensive Assessment policy, dated April 2020, indicated ";Policy: A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician...During the comprehensive patient assessment, all baseline data and other relevant information will be documented...as relevant...an assessment of pain...a physical assessment...imminence of death...complication and risk factors that affect care planning..." During a review of the HAs Spiritual Assessment policy, dated April 2020, the Spiritual Assessment policy indicated, ";Procedure 1. On admission, the hospice registered nurse will conduct an initial spiritual assessment..." During a review of the HAs Psychosocial Assessment policy, dated April 2020, the Psychosocial Assessment policy indicated, ";Policy: A thorough psychosocial assessment will be initiated at the time of admission and continued throughout the course of care." During a review of the HAs Contents of Clinical Record policy, dated April 2020, the Contents of Clinical Record policy indicated, ";Procedure: 1. The following information will be available in the clinical record as applicable to care and services provided...comprehensive and ongoing comprehensive assessments...signed and dated clinical notes...assessment for spiritual care needs..."

Based on observation, interview and record review, the Hospice Agency (HA) failed to review all medications the patients were taking and to update their medication profiles with the currently used medications for two of fourteen sample selected patients (Patient 2 and Patient 13). The patients were at risk for medication errors and adverse drug reactions. This deficient practice had the potential to place the patient at risk for medication errors and adverse drug reactions. --- During an interview on 10/31/2024 at 1:20 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that patients sometimes buy over the counter medications and that is why patients medications need to be reconciled at every nursing visit. The DPCS stated patients medications are reconciled by going over the patients medication list and the actual medication bottles, one by one. The DPCS stated that it was important to reconcile patient medications to identify discrepancies, prevent medication errors, and to reinforce medication safety. 1) During a record review of Patient 2s medical record form titled ";Personal Information," the Personal Information indicated a start of care date of 3/15/2023 with a primary diagnosis of hemiplegia (one side of body weakness) following unspecified cerebrovascular disease affecting left dominant side. During a record review of Patient 2s undated medical record form titled ";Current Treatment/Medication/DME (durable medical equipment)", the DME indicated Patient 2 had six medications listed twice, these included: Atorvastatin (medication to decrease cholesterol), Tamsulosin (medication for the prostate), acetaminophen (pain/fever medication), Norco (narcotic pain medication), Losartan (high blood pressure medication), and Metformin (diabetes medication). The form Current Treatment/Medication/DME also indicated Patient 2 was receiving Santyl, Silvadene, and Therahoney (wound treatment ointment medication). During a concurrent observation, interview, and record review on 10/30/2024 at 1:10 p.m. with License Vocational Nurse 2 (LVN 2) of Patient 2s medication in Patient 2s home, LVN2 stated that she does not have Patient 2s HAs medication list. LVN2 was noted picking up Patient 2s medication bottles one by one, looking at them for a second, then returning them back into his medication box. LVN2 stated that she does not check Patient 2s medication because his family administers his medications. During an interview on 10/30/2024 at 1:20 p.m. with Patient 2s Family Member 5 (FAM5), FAM 5 stated Patient 2 had wounds that were treated and resolved in May 2023. FAM 5 stated Patient 2 only uses Calmoseptine (skin barrier medication) and does not use Silvadene. During an observation on 10/30/2024 at 2 p.m. in Patient 2s home of his prescribed medication bottles, there were seven medication bottles noted. Patient 2s FAM stated the seven medication bottles were the only medications Patient 2 was taking. The medications bottle labels read as following: Glucophage 1000mg (milligrams – unit of measure) one tablet twice a day. Norvasc 10mg one tablet once a day. Tamsulosin 0.4mg one tablet once a day. Atorvastatin 40mg one tablet once a day. Senna 8.6mg one tablet twice a day. Losartan Potassium 100mg one tablet once a day and Plavix 75mg one tablet once a day. 2. 2a. A record review of Patient 13s Personal Information sheet indicated a start of care date on 8/5/2024, with a terminal diagnosis of heart failure (heart is unable to pump blood and oxygen to the body). During a concurrent observation, interview, and record review of the medication review process at the home visit on 10/30/2024, Registered Nurse 3 (RN 3), reviewed the medications Patient 13 was taking, using record titled, ";Current Treatment/Medication/DME", printed on 10/29/2024. The following medications were listed twice in the record: Acetaminophen (to treat pain) 325 mg (mg-milligram, unit of measurement). Amlodipine Besylate (for high blood pressure) 5 mg. Aspirin (to thin the blood) 81 mg. Atorvastatin Calcium (treats fat in the blood-cholesterol) 40 mg. Lorazepam (for anxiety) 0.5 mg. Meloxicam (to treat pain) 7.5 mg. Pantoprazole Sodium (prevents stomach acid) 20 mg. Vitamin D3 (supplement) 1000 units (unit of measurement). Zofran (for nausea) 4mg. Albuterol Sulfate (breathing treatment) HFA 90mcg/actuation (mcg-micrograms, unit of measurement). Nitroglycerin (for chest pain) 0.4 mg. RN 3 stated she did not know why the medications were listed twice in the medication form. 2b. A record review of Patient 13s document titled, ";Current Treatment/Medication/DME List", printed on 10/29/2024, indicated ";Norco 10 mg-325 mg" 1 tablet to be given every 6 hours for severe pain. This was the dose observed at the home visit on 10/30/2024, at 4:38 p.m. During an interview on 10/30/2024, at 4:40 p.m. Patient 13s family (FAM 6) stated Patient 13 had been experiencing hand pain at nights and his current medication ";Norco" (a strong pain reliever) was not helping him. FAM 6 stated she would give Patient 13 Lorazepam (for anxiety) to help him sleep because the hand pain did not let him sleep. FAM 6 stated a nurse told her to give Patient 13 2 tablets of ";Norco" instead of 1, every six hours. During an interview on 11/2/2024, at 12:41 p.m., the DPCS reviewed Patient 13s medical records. The DPCS stated she was not aware Patient 13 was having hand pain. When asked about FAM 6s report of the nurse instructing her to increase Norco tablet from 1 tablet to 2 tablets, the DPCS stated there was no documentation, update in the medical records regarding the hand pain and instructions to increase the Norco tablet to 2 tablets. A record review of the HAs document titled, ";Medication Profile," dated April 2020, indicated, ";Policy: Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications."

Based on interview and record review, the Hospice Agency (HA) failed to conduct an initial bereavement assessment to provide bereavement counseling in accordance with the patient/family's needs for two of fourteen sample selected patients (Patient 3 and Patient 11), 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. This deficient practice had the potential for the patient/family not being provided social, spiritual, and cultural support related to the patient's death. --- 1. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 4/21/2023 with a primary diagnosis of Alzheimers Disease (progressive memory loss) with early onset. During a record review of Patient 3s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no assessments documented. During a concurrent interview and record review on 10/31/2024 at 3:45 p.m. with the Director of Patient Services (DPCS) of Patient 3s Electronic Medical Record (EMR) medical record form titled History of Bereavement Assessment undated, the DPCS stated Patient 3 did not have an initial bereavement assessment. The DPCS stated Patient 3s initial bereavement assessment should have been completed within 5 days of start of care either by the Spiritual Counselor (SC) or the Medical Social Worker (MSW). The DPCS stated when a patients family has not had a bereavement assessment, the family can be in ";shock and frustrated" because they havent been provided the bereavement services. During an interview on 11/1/2024 at 1:06 p.m. with the SC, the SC stated he was unable to log into the HAs EMR system to discuss specific patients. The SC stated he takes care of the patient and their family emotional needs by conducting patients initial and bereavement assessments. During an interview on 11/1/2024 at 1:14 p.m. with the Spiritual Counselor 2 (SC2), the SC2 stated he did not complete Patient 3s initial bereavement assessment due to personal reasons, but that he did let the DPCS know about it. 2. A review of Patient 11s personal information sheet indicated a start of care date on 5/17/2024, for the first hospice certification period to the hospice agency, with a terminal diagnosis of senile degeneration of the brain. During a concurrent interview and record review on 11/2/2024, at 1:00 p.m., the DPCS confirmed there was no initial bereavement assessment done for Patient 11. During a record review of the HAs form titled ";Contents of Clinical Record" revised 4/2020, the form indicated, ";The clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. The following information will be available in the clinical record as applicable to care and services provided: R. Bereavement plan of care, including services being provided. During a record review of the HAs form titled ";Bereavement Assessment" revised 4/2020, the form indicated, ";The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of the patients death as part of the comprehensive assessment."

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss a patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for eight of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 11, Patient 13 and Patient 14). This deficient practice had the potential to result in harm if patients are prevented from reaching their goals, due to IDG not addressing changes in the patient's condition. --- During an interview on 10/31/2024 at 12:30 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated patient assessments are critical. The DPCS stated that the Registered Nurse (RN) does the recertification assessments, first 90 days from the start of care, then every 60 days they need to assess if the patient needs to continue to have hospice care. The assessment is very critical. The DPCS stated patients are assessed and reassessed to make sure they qualify for hospice services. The DPCS stated the IDG (Interdisciplinary group consisting of the Medical Director (MD), the Registered Nurse (RN, Spiritual Counselor (SC) and Medical Social Worker (MSW) meetings are conducted every two weeks in person at the office and occasionally over the phone. The DPCS stated that during the meeting the IDG collaborate to provide patient interventions. During an interview on 10/31/2024 at 1:04 p.m. with the DPCS, the DPCS stated the IDG meetings were important because patients status, change of condition, and review of medications were discussed, and care is planned. During an interview on 10/31/2024 at 1:25 p.m. with the DPCS, the DPCS stated a patients individualized plan of care serves as a guide for visiting nurses. During an interview on 10/31/2024 at 2:45 p.m. with the HAs Electronic Medical Record (EMR) systems representative (RP1), RP1 stated that a red ";X" under the status column indicates that a visit has been created but it has not been submitted for review to the QA (quality assurance) staff. During an interview on 11/1/2024 at 2:07 p.m. with the Medical Director 1 (MD1), MD1 stated being unable to log into the HAs EMR system to discuss specific patients. MD1 stated the HA conducts IDG meetings every other week. MD1 stated there should be documented minutes of the IDG meetings because sometimes he documents and sometimes a nurse does. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 2/5/2024 with a primary diagnosis of chronic obstructive pulmonary disease (difficulty breathing cause by several lung issues). During a record review of Patient 1s medical record form titled ";POC (plan of care) Summary" dated as of 10/29/2024, indicated ";IDT (interdisciplinary team) to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 1s medical record form title ";History of Nursing Assessment" dated 2/5/2024, 4/15/2024, 4/29/2024, 6/10/2024, and 6/24/2024, had a red ";X" under status. During a record review of Patient 1s medical record form title ";Comprehensive Nursing Assessment" dated 2/5/2024, indicated section ";Body System (Head-to-toe)" assessment sections were left blank. The form also indicated sections: ";Imminently Dying, Environmental/Safety, Personal Care and Support Needs, Teaching Needs, Psychosocial Screening, Spiritual Screening, Bereavement Screening, and Referrals were left blank. Lastly the form does not indicate who the author was. During a record review of Patient 1s medical record form title ";Updated Assessment" dated 4/15/2024, indicated the form was left blank. During a record review of Patient 1s medical record form title ";Updated Assessment" dated 4/29/2024, indicated the form was left blank. During a record review of Patient 1s medical record form title ";Updated Assessment" dated 6/10/2024, indicated the form was left blank. During a record review of Patient 1s medical record form title ";Updated Assessment" dated 6/24/2024, indicated the form was left blank. During a record review of Patient 1s medical record form title ";History of POC (plan of care)/IDG (interdisciplinary group)" indicated Patient 1s last interdisciplinary meeting was held on 4/5/2024. During a record review of Patient 1s medical record form title ";POC/IDG Review" dated 2/5/2024, did not indicate the disciplines and their visit frequency. During a record review of Patient 1s medical record form title ";POC/IDG Review" dated 4/5/2024, indicated it was not signed by the Chaplain/Spiritual Counselor. During a record review of Patient 1s medical record form title ";POC Summary" dated as of 10/29/2024, indicated sections allergies, functional limitation/ADL need, mental status, disaster triage, and treatment were left blank. During a concurrent interview and record review on 11/1/2024 at 2:42 p.m. with the DPCS of Patient 1s Electronic Medical Record (EMR) medical record form titled ";Comprehensive Nursing assessment" dated 2/5/2024, the DPCS stated Patient 1s comprehensive assessment was missing a head-to-toe assessment; therefore, it was not complete. The DPCS stated that Patient 1s interventions were created by the visiting License Vocational Nurse (LVN) without the collaboration of the interdisciplinary team. The DPCS stated Patient 1s interventions should have been created by the team. The DPCS stated the patient had the potential to miss out on interventions or treatments needed. The DPCS stated Patient 1s assessments are missing the baseline, which is key to his care. During a concurrent interview and record review on 11/1/2024 at 2:55 p.m. with the DPCS of Patient 1s EMR medical record form titled ";POC Summary" undated, the DPCS stated the form was not complete. The DPCS stated that the POC was completed by the LVN and that it should have been completed by the RN. The DPCS stated that Patient 1s POC is based on his comprehensive assessment, but that there was no comprehensive assessment done. The DPCS stated it was impossible to formulate Patient 1s POC without an RN assessment. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 3/15/2023 with a primary diagnosis of hemiplegia (one side of body weakness) following unspecified cerebrovascular disease affecting left dominant side. During a record review of Patient 2s medical record form titled ";Current Treatment/Medication/DME (durable medical equipment)" undated, indicated ";IDT to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 2s medical record form titled ";POC (plan of care) Summary" dated as of 10/31/2024, indicated ";IDT to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 2s EMR and medical record form titled ";History of Nursing Assessment" indicated a red ";X" listed in the status section under the dates 10/9/2024 to 7/17/2024. The EMR also indicated Patient 2s last documented recertification nursing assessment was documented on 6/7/2023. During a record review of Patient 2s medical record form titled ";Updated Assessment" dated 10/9/2024, indicated section ";Imminently Dying" was left blank. The Updated Assessment form also indicated it did not indicate who the author was. During a record review of Patient 2s EMR medical record form title ";History of History of POC /IDG" indicated Patient 2s last interdisciplinary meeting was held on 5/17/2024. During a concurrent interview and record review on 10/31/2024 at 2:30 p.m. with the DPCS of Patient 2s EMR, medical record form titled ";Updated Assessment" dated 10/9/2024, the DPCS stated Patient 2s Updated Assessment dated 10/9/2024 was not signed by the author. The DPCS stated that with the authors signature, the author attest they documented the note themselves. The DPCS stated that Patient 2 should have had a nursing recertification assessment on 7/31/2024 to determine if he continues to be appropriate for hospice services. The DPCS stated Patient 2 should have been discharged if hospice services were not needed because the HA is limiting Patient 2 in seeking active treatment. During a concurrent interview and record review on 10/31/2024 at 2:30 p.m. with the DPCS of Patient 2s medical record form titled ";History of Nursing Assessment" the DPCS stated the red ";X" listed in the status section indicated the assessment had not been completed. The DPCS stated that the nursing assessment notes attests that the nurse visited and assessed Patient 2. The DPCS stated that when the nursing assessment notes are not in Patient 2s medical record, Patient 2s current status and interventions are unknown. The DPCS stated Patient 2 might not be receiving the care indicated. The DPCS stated, ";If it is not being documented, it means that in our eyes it is not being done, that is our proof." 3. During a record review of Patient 3s medical record form titled ";Personal Information, the form indicated a start of care date of 4/21/2023 with a primary diagnosis of Alzheimers Disease (progressive memory loss) with early onset. During a record review of Patient 3s undated, medical record form titled ";Current Treatment/Medication/DME" indicated ";IDT to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 3s medical record form titled ";POC Summary" dated as of 10/29/2024, indicated ";IDT to review patients status every 14 days and as needed to evaluate changes in condition." During a record review of Patient 3s undated medical record form titled ";History of POC/IDG." the POC form indicated the last entry was made on 8/23/2024. During a record review of Patient 3s medical record form titled ";POC/IDG Review" dated 8/23/2024, the POC indicated it was not signed by the RN and Chaplain. During a record review of Patient 3s medical record form titled ";History of Nursing Assessment." the assessment indicated the last recertification nursing assessment was documented on 8/1/2024. During a concurrent interview and record review on 10/31/2024 3:45 p.m. with the DPCS of Patient 3s EMR medical record form History of POC/IDG, the DPCS stated the last IDG meeting was conducted on 8/23/2024 and was not signed by a Registered Nurse. The DPCS stated all the IDG members needed to sign the IDG meeting the day of the meeting to attest to their presence. 4. During a record review of Patient 4s medical record form titled ";Personal Information," the Personal Information form indicated a start of care date of 4/26/2024 with a primary diagnosis of cerebral infarct due to unspecified occlusion or stenosis of unspecified anterior cerebral artery (brain artery blockage). During a record review of Patient 4s medical record form titled ";POC/IDG Review" dated 6/14/2024, indicated it was not signed by the RN (registered nurse). During a record review of Patient 4s medical record form title ";History of POC/IDG," the POC indicated Patient 4s last interdisciplinary meeting was held on 6/28/2024. During a record review of Patient 4s medical record form titled ";POC/IDG Review" dated 6/28/2024, the POC indicated it was not signed by a RN (registered nurse). During a record review of Patient 4s medical record form titled ";Spiritual Assessment" dated 7/21/2024, the assessment indicated the form was left blank. During a record review of Patient 4s medical record form titled ";History of Psychosocial Assessment," the assessment indicated there were two entries made dated 4/29/2024 and 7/23/2024. During a concurrent interview and record review on 11/1/2024 at 10:37 a.m. with the DPCS of Patient 4s EMR medical record form titled ";History of POC/IDG," the POC indicated Patient 4s last IDG meeting was held on 6/28/2024. The DPCS stated Patient 4s documentation needs to be current to provide ";proper interventions." The DPCS stated patients can ";suffer" without proper interventions. During a concurrent interview and record review on 11/1/2024 at 10:38 a.m. with the DPCS of Patient 4s EMR medical record form titled ";POC/IDG Review" dated 6/14/2024 and 6/28/2024, the POC indicated Patient 4s POC/IDG Reviews were not signed by an RN. The DPCS stated the IDG member signatures indicate they attended the meeting. 5. During a record review of Patient 5s medical record form titled ";Personal Information," the form indicated a start of care date of 5/20/2024 and an end of care date of 9/22/2024, with a primary diagnosis of Alzheimers Disease, unspecified (progressive memory loss). During a record review of Patient 5s medical record form titled ";History of POC/IDG," the POC indicated Patient 5s last interdisciplinary meeting was held on 7/26/2024. During a concurrent interview and record review on 11/1/2024 at 12:15 p.m. with the DPCS of Patient 5s EMR, medical record form titled History of POC/IDG", the DPCS stated Patient 5s last IDG meeting was held on 7/26/2024. The DPCS stated Patient 5s IDG meeting was needed to be able to collaborate and coordinate interventions and any changes of condition. The DPCS stated Patient 5 had the risk of not receiving the proper medications and treatments needed. 6a. A review of Patient 11s Personal Information sheet indicated a start of care date on 4/9/2024, for the first hospice certification period with the hospice agency, with a terminal diagnosis of senile degeneration of the brain. A record review of Patient 11s record titled, POC/IDG review, dated 4/9/2024, indicated that the IDG team needed to review patients status every 14 days and as needed to evaluate a change in condition. During a concurrent interview and record review on 11/1/2024, at 1:45 p.m., by Registered Nurse 1 (RN1) of Patient 11s comprehensive nursing assessment, dated 4/9/2024, RN 1 stated she did an initial assessment for Patient 11 when she was admitted to the HA. RN 1 stated she did not have any wounds at the time of admission. Patient 11 did have, however, non-blanchable (redness in the right buttocks and sacrum area (the area between the buttocks, at the end of the spine). A record review of Patient 11s updated assessment, dated 4/22/2024 indicated, the wounds were measured in centimeters (cm-unit of measurement), in the order of length (L) x (by) width (W) x depth (D). Patient 11s right buttocks, Stage 3 measured 8 cm x 9.6 cm x 0.1 cm. and had serosanguineous (fluid and blood) discharge. The Stage 2 sacrum wound measured 4cm x 8 cm x 0 cm. A record review of Patient 11s record titled, POC/IDG review, dated 4/24/2024, indicated that the IDG team needed to review the patients status every 14 days and as needed to evaluate change in condition. During a concurrent interview and record review on 11/1/2024, at 1:54 p.m., by RN 1 of Patient 11s updated nursing assessment, dated 4/22/2024, RN1 stated she was the nurse who had visited the patient as part of the routine 14 day visit as indicated in the plan of care. RN 1 stated Patient 11s wounds progressed from non-blanchable redness on the right buttocks and sacrum, to a Stage 2 pressure wound (when the skin opens, wears away, or forms an ulcer. Usually tender or painful) to the sacrum and Stage 3 pressure wound (an opening through the skin into the deeper tissue and fat) to the right buttocks. During a concurrent interview and record review on 11/1/2024, at 3:41 p.m. the DPCS reviewed Patient 11s record titled, Updated Assessment, dated 4/22/2024. The DPCS stated the treatment given on 4/9/2024 (skin barrier) was not effective, and this required a change to the plan of care. Patient 11s wounds had progressed from non-blanchable redness in the right buttocks and sacrum, to a Stage 2 (sacrum) and Stage 3 (right buttocks). The DPCS stated she had called MD 1 on 4/22/204 and a new treatment order was given. The DPCS stated the IDG group needed to meet to discuss the change of condition and update the plan of care because Patient 11 had experienced a change of condition. The DPCS stated the IDG group did not meet. The DPCS stated the IDG group needed to update the plan of care because on 4/22/2024, the treatment orders required a frequency of every three days. An increase of skilled nurse visits was needed to two to three times a week, to provide wound treatment and assessment. The DPCS stated if the wounds were not assessed, they can progress, cause infection, infection can cause bacteremia and sepsis, which can facilitate the death process. 6b. A review of Patient 11s Personal Information record indicated a second certification admission on 4/24/2024, with a terminal diagnosis of senile degeneration of the brain. During a concurrent interview and record review on 11/1/2024, at 4 p.m., the DPCS reviewed Patient 11s Comprehensive Assessment, dated 4/24/2024. The DPCS stated Patient 11s wound size increased significantly compared to the previous assessment on 4/22/2024. Patient 11s Stage 3 right buttocks wound increased to 13.5 cm x 10 cm x 0.2 cm , with serosanguinous drainage and mild odor. The Stage 2 sacrum wound increased to 5 cm x 9.7 cm x 0cm, with serosanguinous drainage. A continued review of the document indicated the wound treatment documented was the same treatment as the one done on 4/22/2024. When asked about why the treatment order was the same even though there were changes in the wound assessment, the DPCS initially stated she had spoken to MD 1 and he had given the same wound care orders as 4/22/2024. The DPCS stated MD 1 had not ordered a wound consult. A record review of Patient 11s, plan of care, dated 5/11/2024, indicated RN 1 was to visit Patient 11 every 14 days, and the skilled nurse was to visit once a week. During a concurrent interview and record review on 11/1/2024, at 4:25p.m., the DPCS reviewed Patient 11s, Updated Assessment, dated 5/8/2024. The DPCS stated the record indicated the wounds were worsening and increasing in size. The sacrum Stage 2 wound increased to 6 cm x 10 cm x 0.1 cm, with serosanguinous drainage. The right buttocks, Stage 4 increased to 15 cm x 12 cm x 0.3 cm, serosanguinous with mild odor. The DPCS stated providing more nursing visits would have helped to prevent the wound from worsening. The nurses would have assessed more frequently and updated the doctor to see if the plan and treatment needed to change. The DPCS stated the wound consultant saw Patient 11 on 5/7/2024. ---------Start HEre Tomorrow 11/13/24 During an interview on 11/2/2024, at 10:48 a.m., the DPCS stated the IDG team met to discuss the wound assessment of 5/8/2024, but this meeting was not documented. The DPCS stated she did not remember when the meeting occurred. The DPCS stated the plan of care was not updated when wound changes were identified on 5/8/2024. The DPCS stated it was important to update the plan of care to make sure the team would be able to be aware of Patient 11s status, to collaborate, so things do not fall into the cracks. The DPCS stated Patient 11s wound assessment of 5/8/2024 required more visits. When asked what can happen if wounds are not assessed, the DPCS stated there was a possibility for the patients care to be affected, wounds can worsen. For Patient 11, the wounds got worse. 7. A record review of Patient 13s Personal Information sheet indicated a start of care date on 8/5/2024, with a terminal diagnosis of heart failure (heart is unable to pump blood and oxygen to the body). During an observation of the home visit on 10/30/2024, at 4:15p.m., Registered Nurse 3 (RN 3) checked Patient 13s blood pressure. Patient 13s blood pressures were 202/205 on the left arm and 192/100 on the right arm. (Normal ranges are 120/80. The first number is the reading of the heart pumping blood. The second number is the reading of the heart relaxing). During an observation of the home visit on 10/30/2024, at 4:30 p.m. RN 3 gave Patient 13 a medication called Clonidine (to lower the blood pressure). During a concurrent observation and interview on 10/30/2024, at 4:45 p.m., RN 3 checked Patient 13s blood pressure. RN 3 stated Patient 13s blood pressure was 177/94 on the right arm and 181/94 on the left arm. RN 3 stated she would call the doctor today to inform about Patient 13s blood pressure readings. A record review of the nursing visit notes indicated Patient 13s blood pressures: 10/30/24: 202/105 10/4/24: 176/100 10/11/24: 164/71 10/18/24: 189/85 10/25/24: 159/92 During a concurrent interview and record review on 11/2/2024, at 12:25 p.m., the DPCS reviewed Patient 13s records titled, ";POC/IDG", for dates 8/5/24, 8/23/24, 9/6/24, 9/20/24,10/4/24, and 10/18/24. All the records indicated Patient 13s blood pressure to be 177/109. The DPCS stated Patient 13s blood pressure readings were not discussed in the IDG meetings. The DPCS stated Patient 13s blood pressure readings should have been discussed because the readings could possibly require a change in the plan of care, a change of the medications for blood pressure management. When asked if the doctor had been informed about Patient 13s blood pressure readings, the DPCS stated the doctor was informed but there was no documentation of such communication. A record review of Patient 13s nursing visit note on 10/30/2024 indicated RN 3 notified MD 1 of Patient 13s blood pressure readings during the visit. The note indicated MD 1 had increased the dosages of Patient 13s blood pressure medications, Amlodopine and Clonidine. 8. A record review of Patient 14s Personal Information sheet indicated a start of care date on 1/19/2024, with a terminal diagnosis of heart disease. During an interview on 10/30/2024, at 1:08 p.m., Patient 14s family member (FAM 7) stated Patient 14 was waiting for a surgery appointment for his hip. FAM 7 stated Patient 14 originally had surgery on January 2024 and screws were placed in his hip and leg. FAM 7 stated his body was rejecting the screws and had to have another surgery to fix the problem. FAM 7 stated Patient 14 was having issues walking due to the hip pain. During a concurrent interview and record review on 11/2/2024, at 12:20 p.m., the DPCS reviewed Patient 14s IDG notes. The DPCS stated the last documented IDG note was on 5/3/2024. The DPCS stated the IDG group had met but the discussion about Patient 14s care was not documented. The DPCS stated it was important to document the IDG meetings for Patient 14 because it is to attest that the IDG group gathered to discuss the patients care, intervention, and if further treatment is needed. The DPCS stated she was not aware Patient 14 was going to have surgery, was experiencing hip pain, and was having difficulty walking due to the hip pain. The DPCS stated Patient 14s hip pain was not documented in the medical records. When asked if his current pain management was effective, the DPCS stated, ";yes, otherwise he would have called us. No, nothing is documented if his pain management is working or not." During a record review of the HAs form titled ";Contents of Clinical Record" revised 4/2020, the form indicated, ";The clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. The following information will be available in the clinical record as applicable to care and services provided: C. Patient and family/caregiver initial, comprehensive, and ongoing comprehensive assessments. Each entry will be dated and signed, including title and credentials, by the person providing the care/service. During a record review of the HAs form titled ";Interdisciplinary Group Membership and Responsibilities" revised 4/2020, the form indicated, ";The interdisciplinary group will collaborate with the patients attending physician to develop and individualized plan of care. The hospice interdisciplinary group membership includes at a minimum: Physician, registered Nurse, Social Worker, and Pastoral or other counselor. The interdisciplinary group responsibilities include but are not limited to: Participate in the establishment of the plan of care for each patient admitted to the hospice service. Participation in the periodic review and updating of the plan of care for each patient receiving hospice services." During a record review of the HAs form titled ";Admission Criteria and Process" revised 4/2020, the form indicated, ";Eligibility criteria will be continually reviewed on an ongoing basis by the interdisciplinary team to assure appropriateness of hospice care." During a record review of the HAs form titled ";The Plan of Care" revised 4/2020, the form 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 bit no less that every fifteen (15) days.

Based on observation, interview and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for Interdisciplinary group, care planning, and coordination of services as follows: --- 1. The HA failed to complete and sign the documentation for the ";IDG" section of the assessment for three of 14 sampled patients (Patient 7, Patient 8, and Patient 9). This failure to not have the document signed by each person attending the meeting resulted in the medical charts for Patient 7, Patient 8, and Patient 9 to be incomplete. (Refer to L540). 2. The HA failed to ensure two of fourteen sample patients (Patient 1 and Patient 2) individualized plan of care were followed. (Refer to L543). 3. The HA failed to develop four of fourteen sample patients (Patient 1, Patient 11, Patient 13, and Patient 14) individualized plan of care based on his initial, comprehensive, and updated nursing assessments. (Refer to L545). 4. The HA failed to ensure that ordered visits were done for three of 14 sampled patients. (Patient 7, Patient 8, and Patient 9). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with Federal regulations for Interdisciplinary group, care planning, and coordination of services. This deficient practice placed these patients in a position where they did not receive their physician ordered care.

Based on interview and record review, the facility failed to complete the documentation for the ";IDG" section of the assessment for three of 14 sampled patients (Patient 7, Patient 8, and Patient 9). This failure to have the document signed by each person attending the meeting left the medical charts for Patient 7, Patient 8, and Patient 9 incomplete. --- a). During a review of Patient 7s ";Face Sheet" it indicated he was admitted to the hospice agency on 4/12/24 with a primary diagnosis of heart disease of the native coronary artery (arteries that supply blood to the heart). During a review of Patient 7s ";POC/IDG review" under frequency of visits, it indicated the agency would conduct HA visits once week, MSW visits every recert, Spiritual counselor visits every recert, SN visits once a week, and RN visits one to two times per week. A review of Patient 7"s ";IDG" (Interdisciplinary group) notes for the following dates, indicated there were no RN signatures provided. 6/28/24 7/26/24 8/9/24, 8/23/24 9/6/24, 9/20/24 During an interview on 11/1/24 at 3:05pm with the DPCS, she stated when asked about the missing RN signatures for the IDG for the requested patients, the DPCS stated RN signatures were missing and should be there, she stated it should be her signature, or the RN who started the case, that should be on the IDGs every two weeks for each patient. She stated that she ultimately has the responsibility to ensure all signatures are there but it was not done. b). During a review of Patient 8s ";Face Sheet" the Facesheet indicated he was admitted to the hospice agency on 6/4/24 with a primary diagnosis of cerebral infarction (blockage in the blood vessels supplying blood to the brain). During a review of Patient 8s ";POC/IDG review" under frequency of visits, it indicated to conduct MSW visits every recert, Spiritual counselor visits every recert, SN visits once per week, and RN visits one to two times per weeks. A review of Patient 8s ";IDG" (Interdisciplinary group) notes for the following dates was done: 6/4/24, 6/28/24 7/12/24 7/26/24 8/9/24 8/23/24 9/6/24 9/20/24 During an interview on 11/1/24 at 3:05pm with the DPCS, she stated when asked about the missing RN signatures for the IDG for requested patients, the DPCS stated RN signatures were missing and should be there, she stated it should be her signature, or the RN who started the case that should be on the IDGs every two weeks for each patient. She stated that she ultimately has the responsibility to ensure all signature are there but it was not done. c). During a review of Patient 9s ";Face Sheet" it indicated he was admitted to the hospice agency on 12/31/23 with a primary diagnosis of hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 9s ";POC/IDG review" under the frequency of visits, it indicated Patient 9 had CHHA visits twice per week, SN visits once per week (1/week), MSW visits 1/recertification, SC visits 1/recertification and RN visits one to two times per week (1/2 weeks). A review of patient 9s ";IDG" (Interdisciplinary group) notes of the following dates was done: 5/31/24, 6/14/24, 6/28/24, 7/12/24, 7/26/24, 8/9/24, 8/23/24, and 9/6/24 During an interview on 11/1/24 at 3:05 pm with the DPCS, the DPCS stated when asked about the missing RN signatures for the IDG's for the requested patients, the DPCS stated RN signatures were missing and should be there. She stated it should be her signature, or the RN who started the case that should be on the IDG's every two weeks for each patient. She stated that she ultimately has the responsibility to ensure all signatures are there and it was not done. During a review of the agencys policy entitled "; Interdisciplinary group membership and responsibilities" dated April 2020, the policy indicated, the Interdisciplinary group will collaborate with the patients attending physician to develop an individualized written plan

Based on interview and record review, the Hospice Agency (HA) failed to ensure two of fourteen sample patients (Patient 1 and Patient 2) individualized plans of care were followed. This failure had the potential to result in preventing patients from reaching their care planning goals. --- During an interview on 10/31/2024 at 1:35 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the HA expected the visiting nurses to document their patients visit notes in the HAs Electronic Medical Record (EMR) within 24-48 hours after their visits. The DPCS stated that the patients visit notes served as proof that they were visited and received hospice services. The DPCS stated that the patients visit notes are used to communicate the patients current status in order to coordinate and collaborate the patients care. During an interview on 10/31/2024 at 2:45 p.m. with the HAs Electronic Medical Record (EMR) systems representative (RP1), RP1 stated that a red ";X" under the status column indicates that a visit has been created but it has not been submitted for review to the QA (quality assurance) staff. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 2/5/2024 with a primary diagnosis of chronic obstructive pulmonary disease (difficulty breathing cause by several lung issues). During a record review of Patient 1s medical record form title ";History of Visit Notes" indicated a red ";X" under status on the LVN (License Vocational Nurse) visit notes dated May 11 & 25, April 13 & 27, March 13 & 27 2024. During a record review of Patient 1s medical record form title ";Visit Note LVN" dated 4/13/2024, indicated form was left blank. During a record review of Patient 1s medical record form title ";Visit Note LVN" dated 4/27/2024, indicated form was left blank. During a record review of Patient 1s medical record form title ";Visit Note LVN" dated 5/11/2024, did not indicate who the author was. During a record review of Patient 1s medical record form title ";History of POC (plan of care)/IDG (interdisciplinary group)" indicated Patient 1s last interdisciplinary meeting was held on 4/5/2024. During a record review of Patient 1s medical record form title ";POC/IDG Review" dated 4/5/2024, indicated Patient 1 was to receive Skilled Nurse (SN) visits once per week and one as needed." During a record review of Patient 1s medical record form title ";POC (plan of care)/Summary" dated as of 10/29/2024, indicated sections allergies, functional limitation/ADL need, mental status, disaster triage, and treatment were left blank. The POC Summary also indicated Patient 1 was to receive Skilled Nurse (SN) visits once per week and one as needed." During a concurrent interview and record review on 11/1/2024 at 2:42 p.m. with the Director of Patient Care Services (DPCS) of Patient 1s Electronic Medical Record (EMR) medical record forms titled ";Visit Note LVN" dated 4/13/2024, 4/27/2024, and 5/11/2024, the DPCS stated there was nothing documented. The DPCS stated the forms should be completed by the visiting nurse on the day of the visit to confirm Patient 1 was seen and care was provided. The DPCS stated not knowing why the visiting nurse notes were not there. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 3/15/2023 with a primary diagnosis of hemiplegia (one side of body weakness) following unspecified cerebrovascular disease affecting left dominant side. During a record review of Patient 2s medical record form titled ";History of Visit Notes" indicated the last entry made was dated on 9/16/2024. The History of Visit Notes also indicated a red ";X" under status on the LVN (License Vocational Nurse) visit notes dated July 3, 10, 17, 2024; June 5, 12, 19, 26, 2024; and May 8, 15, 19, 22, 29, 2024. A record review of Patient 2s medical record form titled ";Visit Note LVN" dated 7/3/2024, indicated the form was left blank. A record review of Patient 2s medical record form titled ";Visit Note LVN" dated 7/10/2024, indicated the form was left blank. A record review of Patient 2s medical record form titled ";Visit Note LVN" dated 7/17/2024, did not indicate who the author was. A record review of Patient 2s EMR medical record form titled ";History of POC (plan of care)/IDG (interdisciplinary group)" indicated Patient 2s last interdisciplinary meeting was held on 5/17/2024. A record review of Patient 2s medical record form titled ";POC Summary" dated as of 10/31/2024, indicated Patient 2s allergies were not documented. The POC Summary also indicated Patient 2 was to receive Skilled Nurse (SN) visits once per week and one as needed." During a concurrent interview and record review on 10/31/2024 at 2:30 p.m. with the DPCS of Patient 2s EMR medical record forms titled ";Visit Note LVN" dated July 3, 10, 17, 2024; June 5, 12, 19, 26, 2024; and May 8, 15, 19, 22, 29, 2024, the DPCS stated the red ";X" listed under the status section means that the notes have not been completed. The DPCS stated the nursing notes attests that the nurse visited and assessed the patient. The DPCS stated Patient 2s last interdisciplinary group meeting was held on 5/17/2024, according to his medical record. The DPCS stated Patient 2s needs may not be addressed if there isnt anything to go by. The DPCS stated, ";Documentation is important." During a record review of the HAs form titled ";Missed Visits" revised 4/2020, the form indicated, ";Missed visits will be communicated to the interdisciplinary group at the IDG meeting. A missed visit will be rescheduled the same week, if possible. Missed visits will be documented in the clinical record." During a record review of the HAs form titled ";The Plan of Care" revised 4/2020, the form indicated, ";The care provided to the patient must be in accordance with the plan of care. During a record review of the HAs form titled ";Admission Criteria and Process" revised 4/2020, the form indicated, ";The patients wishes/desires will be considered and respected in the development of the plan of care."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to develop four of fourteen sample patients (Patient 1, Patient 11, Patient 13, and Patient 14) individualized plan of care based on his initial, comprehensive, and updated nursing assessments. This deficient practice resulted in care being provided without identifying the care the patient needed based on their needs. --- During an interview on 10/31/2024 at 12:30 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated patients assessments are critical. DPCS stated that The Registered Nurse (RN) does the recertification assessments (complete physical, social, and spiritual assessment to determine if a patient continues to meet hospice eligible criteria), first 90 days from start of care then every 60 days to they need to assess if the patient needs to continue to have hospice care. The assessment is very critical. The DPCS stated patients are assessed and reassessed to make sure they qualify for hospice services. The DPCS stated the IDG (interdisciplinary group consisting of the Medical Director (MD), the Medical Social Worker (MSW), the Spiritual Counselor or Chaplin (SC), and an RN) meetings are conducted every two weeks in person at the office and occasionally over the phone. The DPCS stated that during the meeting the IDG collaborate to provide patient interventions. During an interview on 10/31/2024 at 1:04 p.m. with the DPCS, the DPCS stated the IDG meetings were important because patients status, change of condition, and review of medications were discussed, and care is planned. During an interview on 10/31/2024 at 1:25 p.m. with the DPCS, the DPCS stated a patients individualized plan of care serves as a guide for visiting nurses. During an interview on 10/31/2024 at 2:45 p.m. with the HAs Electronic Medical Record (EMR) systems representative (RP1), RP1 stated that a red ";X" under the status column indicates that a visit has been created but it has not been submitted for review to the QA (quality assurance) staff. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 2/5/2024 with a primary diagnosis of chronic obstructive pulmonary disease (difficulty breathing cause by several lung issues). During a record review of Patient 1s medical record form titled ";History of Nursing Assessment" dated 2/5/2024, 4/15/2024, 4/29/2024, 6/10/2024, and 6/24/2024, had a red ";X" under status. A record review of Patient 1s medical record form title ";Comprehensive Nursing Assessment" dated 2/5/2024, indicated the section for ";Body System (Head-to-toe)" assessment sections were left blank. The form also indicated sections for ";Imminently Dying, Environmental/Safety, Personal Care and Support Needs, Teaching Needs, Psychosocial Screening, Spiritual Screening, Bereavement Screening, and Referrals were left blank. Lastly the form does not indicate who the author was. During a record review of Patient 1s medical record form titled ";Updated Assessment" the assessment dated 4/15/2024, indicated the form was left blank. During a record review of Patient 1s medical record form titled ";Updated Assessment" dated 4/29/2024, the assessment indicated the form was left blank. During a record review of Patient 1s medical record form titled ";Updated Assessment" dated 6/10/2024, the assessment indicated the form was left blank. During a record review of Patient 1s medical record form titled ";Updated Assessment" dated 6/24/2024, the assessment indicated the form was left blank. During a record review of Patient 1s medical record form titled ";History of POC (plan of care)/IDG" the POC indicated Patient 1s last interdisciplinary meeting was held on 4/5/2024. During a record review of Patient 1s medical record form titled ";POC/IDG Review" dated 2/5/2024, the POC did not indicate the disciplines and their visit frequency. During a record review of Patient 1s medical record form titled ";POC/IDG Review" dated 4/5/2024, the POC indicated it was not signed by the Chaplain/Spiritual Counselor. During a record review of Patient 1s medical record form titled ";POC Summary" dated as of 10/29/2024, the POC Summary indicated sections allergies, functional limitation/ADL need, mental status, disaster triage, and treatment were left blank. During a concurrent interview and record review on 11/1/2024 at 2:42 p.m. with the DPCS of Patient 1s EMR medical record form titled ";Comprehensive Nursing assessment" dated 2/5/2024, the DPCS stated Patient 1s comprehensive assessment was missing a head-to-toe assessment; therefore, it was not complete. The DPCS stated that Patient 1s interventions were created by the visiting License Vocational Nurse (LVN) without the collaboration of the interdisciplinary team. The DPCS stated Patient 1s interventions should have been created by the team. The DPCS stated the patient had the potential to miss out on interventions or treatments needed. The DPCS stated Patient 1s assessments are missing the baseline, which is key to his care. During a concurrent interview and record review on 11/1/2024 at 2:55 p.m. with the DPCS of Patient 1s undated, EMR medical record form titled ";POC Summary" the DPCS stated the form was not complete. The DPCS stated that the POC was completed by the LVN and that it should have been completed by the RN. The DPCS stated that Patient 1s POC is based on his comprehensive assessment, but that there was no comprehensive assessment done. The DPCS stated it was impossible to formulate Patient 1s POC without an RN assessment. 2. A review of Patient 11s personal information sheet indicated a start of care date on 4/9/2024, for the first hospice certification period with the hospice agency, with a terminal diagnosis of senile degeneration of the brain. During a concurrent interview and record review on 11/1/2024, at 1:45 p.m., by Registered Nurse 1 (RN1) of Patient 11s comprehensive nursing assessment, dated 4/9/2024, RN 1 stated she completed the initial assessment for Patient 11 when she was admitted to the HA. RN 1 stated she did not have any wounds at the time of admission. Patient 11 did however, have non-blanchable (redness in the right buttocks and sacrum area (the area between the buttocks, at the end of the spine). During a concurrent interview and record review on 11/1/2024, at 1:54 p.m., by RN 1 of Patient 11s updated nursing assessment, dated 4/22/2024, RN1 stated she was the nurse who had visited the patient as part of the routine 14 day visit as indicated in the plan of care. RN 1 stated Patient 11s wounds progressed from non-blanchable redness on the right buttocks and sacrum, to a Stage 2 pressure wound (when the skin opens, wears away, or forms an ulcer. Usually tender or painful) to the sacrum and Stage 3 pressure wound (an opening through the skin into the deeper tissue and fat) to the right buttocks. A record review of Patient 11s record titled, POC/IDG review, dated 4/9/2024, indicated that the IDG team needed to review patients status every 14 days and as needed to evaluate a change in condition. During a concurrent interview and record review on 11/1/2024, at 3:41 p.m. the DPCS reviewed Patient 11s record titled, Updated Assessment, dated 4/22/2024. The DPCS stated the treatment given on 4/9/2024 (skin barrier) was not effective, and this required a change to the plan of care. Patient 11s wounds had progressed from non-blanchable redness in the right buttocks and sacrum, to Stage 2 to the sacrum and a Stage 3 to the right buttocks. The DPCS stated she had called the MD 1 on 4/22/204 and a new treatment order was given. The DPCS stated the IDG group needed to meet to discuss the change of condition and update the plan of care because Patient 11 had experienced a change of condition. The DPCS stated the IDG group did not meet. The DPCS stated the IDG group needed to update the plan of care because on 4/22/2024, the treatment orders required a frequency of every three days. An increase of skilled nurse visits was needed to two to 3 times a week, to provide wound treatment and assessment. The DPCS stated if the wounds were not assessed, they can progress, cause infection, infection can cause bacteremia and sepsis, which can facilitate the death process. A record review of Patient 11s updated assessment, dated 4/22/2024 indicated, the wounds were measured in centimeters (cm-unit of measurement), in the order of length (L) x (by) width (W) x depth (D). Patient 11s right buttocks, Stage 3 measured 8 cm x 9.6 cm x 0.1 cm. and had serosanguineous (fluid and blood) discharge. The stage 2 sacrum wound measured 4cm x 8 cm x 0 cm. 2b. A review of Patient 11s personal information record indicated a second certification admission on 4/24/2024, with a terminal diagnosis of senile degeneration of the brain. During a concurrent interview and record review on 11/1/2024, at 4 p.m., the DPCS reviewed Patient 11s Comprehensive Assessment, dated 4/24/2024. The DPCS stated Patient 11s wound size increased significantly compared to the previous assessment on 4/22/2024. Patient 11s Stage 3 right buttocks wound increased to 13.5 cm x 10 cm x 0.2 cm , with serosanguinous drainage and mild odor. The Stage 2 sacrum wound increased to 5 cm x 9.7 cm x 0cm, with serosanguinous drainage. A continued review of the document indicated the wound treatment documented was the same treatment as the one done on 4/22/2024. When asked about why the treatment order was the same even though there were changes in the wound assessment, the DPCS initially stated she had spoken to MD 1 and he had given the same wound care orders as 4/22/2024. The DPCS stated MD 1 had not ordered a wound consult. A record review of Patient 11s, plan of care, dated 5/11/2024, indicated RN 1 was to visit Patient 11 every 14 days, and the skilled nurse was to visit once a week. During a concurrent interview and record review on 11/1/2024, at 4:25p.m., the DPCS reviewed Patient 11s, Updated Assessment, dated 5/8/2024. The DPCS stated the record indicated the wounds were worsening, increasing in size. The sacrum Stage 2 wound increased to 6 cm x 10 cm x 0.1 cm, with serosanguinous drainage. The right buttocks, Stage 4 increased to 15 cm x 12 cm x 0.3 cm, serosanguinous with mild odor. The DPCS stated providing more nursing visits would have helped in preventing the wound from worsening. The nurses would have assessed more frequently and updated the doctor to see if the plan and treatment needed to change. The DPCS stated the wound consultant saw Patient 11 on 5/7/2024. A record review of Patient 11s record titled, POC/IDG review, dated 4/242024, indicated that the IDG team needed to review the patients status every 14 days and as needed to evaluate change in condition. During an interview on 11/2/2024, at 10:48 a.m., the DPCS stated the IDG team met to discuss the wound assessment of 5/8/2024, but this meeting was not documented. The DPCS stated she did not remember when the meeting occurred. The DPCS stated the plan of care was not updated when wound changes were identified on 5/8/2024. The DPCS stated it was important to update the plan of care to make sure the team would be able to be aware of Patient 11s status, to collaborate, so things do not fall into the cracks. The DPCS stated Patient 11s wound assessment of 5/8/2024 required more visits. When asked what can happen if wounds are not assessed, the DPCS stated there was a possibility for the patients care to be affected, wounds can worsen. For Patient 11, the wounds got worse. 3. A record review of Patient 13s Personal Information sheet indicated a start of care date on 8/5/2024, with a terminal diagnosis of heart failure (heart is unable to pump blood and oxygen to the body). During an observation of the home visit on 10/30/2024, at 4:15p.m., Registered Nurse 3 (RN 3) checked Patient 13s blood pressure. Patient 13s blood pressures was 202/205 on the left arm and 192/100 on the right arm. (Normal ranges are 120/80. The first number is the reading of the heart pumping blood. The second number is the reading of the heart relaxing). During an observation of the home visit on 10/30/2024, at 4:30 p.m. RN 3 gave Patient 13 a medication called Clonidine (to lower the blood pressure). During a concurrent observation and interview on 10/30/2024, at 4:45 p.m., RN 3 checked Patient 13s blood pressure. RN 3 stated Patient 13s blood pressure was 177/94 on the right arm and 181/94 on the left arm. RN 3 stated she would call the doctor today to inform about Patient 13s blood pressure readings. A record review of the nursing visit notes indicated Patient 13s blood pressures were as follows: 10/30/24: 202/105 10/4/24: 176/100 10/11/24: 164/71 10/18/24: 189/85 10/25/24: 159/92 During a concurrent interview and record review on 11/2/2024, at 12:25 p.m., the DPCS reviewed Patient 13s records titled, ";POC/IDG", for dates 8/5/24, 8/23/24, 9/6/24, 9/20/24,10/4/24, and 10/18/24. All the records indicated Patient 13s blood pressure to be 177/109. The DPCS stated Patient 13s blood pressure readings were not discussed in the IDG meetings. The DPCS stated Patient 13s blood pressure readings should have been discussed because the readings could possibly require a change in the plan of care, a change of the medications for blood pressure management. When asked if the doctor had been informed about Patient 13s blood pressure readings, the DPCS stated the doctor was informed but there was no documentation of such communication. A record review of Patient 13s nursing visit note on 10/30/2024 indicated RN 3 notified MD 1 of Patient 13s blood pressure readings during the visit. The note indicated MD 1 had increased the dosages of Patient 13s blood pressure medications, Amlodipine and Clonidine. 4. A record review of Patient 14s Personal Information sheet indicated a start of care date on 1/19/2024, with a terminal diagnosis of heart disease. During an interview on 10/30/2024, at 1:08 p.m., Patient 14s family member (FAM 7) stated Patient 14 was waiting for a surgery appointment for his hip. FAM 7 stated Patient 14 originally had surgery on January 2024 and screws were placed in his hip and leg. FAM 7 stated his body was rejecting the screws and had to have another surgery to fix the problem. FAM 7 stated Patient 14 was having issues walking due to the hip pain. During a concurrent interview and record review on 11/2/2024, at 12:20 p.m., the DPCS reviewed Patient 14s IDG notes. The DPCS stated the last documented IDG note was on 5/3/2024. The DPCS stated the IDG group had met but the discussion about Patient 14s care was not documented. The DPCS stated it was important to document the IDG meetings for Patient 14 because it is to attest that the IDG group gathered to discuss the patients care, intervention, and if further treatment is needed. The DPCS stated she was not aware Patient 14 was going to have surgery, was experiencing hip pain, and was having difficulty walking due to the hip pain. The DPCS stated Patient 14s hip pain was not documented in the medical records. When asked if his current pain management was effective, the DPCS stated, ";Yes, otherwise he would have called us. No, nothing is documented if his pain management is working or not." During a record review of the HAs form titled ";Interdisciplinary Group Membership and Responsibilities" revised 4/2020, the form indicated, ";The interdisciplinary group will collaborate with the patients attending physician to develop and individualized plan of care. The hospice interdisciplinary group membership includes at a minimum: Physician, registered Nurse, Social Worker, and Pastoral or other counselor. The interdisciplinary group responsibilities include but are not limited to: Participate in the establishment of the plan of care for each patient admitted to the hospice service. Participation in the periodic review and updating of the plan of care for each patient receiving hospice services." During a record review of the HAs form titled ";The Plan of Care" revised 4/2020, the form 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 bit no less that every fifteen (15) days. During a record review of the HAs form titled ";Initial Assessment" revised 4/2020, the form indicated, ";Based on the initial assessment, the plan of care will be initiated on the day of admission."

Based on interview, and record review, the agency failed to ensure that ordered visits were done for three of 14 sampled patients (Patient 7, Patient 8 and Patient 9). This deficient practice placed patients in a position where they did not receive their physician ordered care. --- a). During a review of Patient 7s ";Face sheet" the Facesheet indicated he was admitted to the hospice agency on 4/12/24 with a primary diagnosis of heart disease of the native coronary artery (arteries that supply blood to the heart). During a review of Patient 7s ";POC/IDG review" under frequency of visits, it indicated HA visits one visit per week (1/week), MSW visits every recert, Spiritual counselor visits every recert, SN visits once per week (1/week), and RN visits one to two times per week (1/ 2) weeks. b). During a review of Patient 7s ";Visit notes" in the EMR it indicated a missed SN visits every other week between the following dates 4/19/24 to 8/9/24. During an interview on 11/1/24 at 3:05 pm with the DPCS in the agency office, she stated that Patient 7 had a SOC of 4/12/24 with orders for once per week (1/week) SN visits. She stated those visits were not being made and no documentation could be provided for the missed days. The DPCS stated documentation for SN visits shows up in the EMR after 8/9/24 until present. The DPCS stated that missed visits are important to communicate with the MD. She further stated it should be attempted to be rescheduled with the family for a time that is close to the missed appointment. c). During a review of Patient 8s ";Face sheet" the Facesheet indicated he was admitted to the hospice agency on 6/4/24 with a primary diagnosis of cerebral infarction (blockage in the blood vessels supplying blood to the brain). During a review of Patient 8s ";POC/IDG review" under frequency of visits, it indicated MSW visits every recert, Spiritual counselor visits every recert, SN visits 1/week, and RN visits 1/ 2 weeks. During a review of Patient 8s ";Visit notes" in the EMR, the EMR indicated no visits were made from the SOC 6/4/24 to the present for Patient 8's home visits. She further stated that she is ultimately responsible to ensure that all patients are receiving their MD ordered care which was not done for Patient 8. During an interview on 10/31/24 at 1:40 pm with RN2, she stated nursing notes for Patient 8 were not documented in the agencys EMR. She stated that all ordered visits were made and not missed for Patient 8, however, she did not complete each visit by documenting in the EMR for Patient 8. During an interview on 11/1/24 at 3:05 pm with the DPCS, she stated that Patient 8s SOC was 6/4/24, she further stated that no visit notes were in the EMR to print out. She further stated that it was her ultimate responsibility to ensure that each patient was receiving what the MD had ordered for them and this was not done for Patient 8. d). During a review of Patient 9s ";Face sheet," the Facesheet indicated he was admitted to the hospice agency on 12/31/23 with a primary diagnosis of hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 9s ";POC/IDG review" under the frequency of visits, the POC indicated she had HA visits 2/week, SN 1/week, MSW visits 1/recertification, SC visits 1/recertification and RN visits 1/2 weeks. During a review of Patient 9s ";Visit notes" in the EMR it indicated no visits were made for the following dates 3/10/24 to 5/19/24 and 8/8/24 to 10/31/24. During a phone interview on 10/31/24 at 1:40 pm with RN2 she stated that even though some home visits were not documented, the actual home visits were made and Patient 9 did not miss a visit. RN2 stated from 3/10/24 to 5/19/24 and 8/8/24 to 10/31/24 documentation for each visit did not get entered into the agencys EMR. She stated the actual home visit was made but she did not document into the EMR. RN2 stated that agency management is aware of the issue and has given her until the 15th of this month (November 2024) to enter all her information for all her patients. During a phone interview on 11/1/24 at 3:05 pm with the DPCS, she stated that Patient 9s SOC was on 12/31/23, and the first visit note in the EMR is dated 2/14/24. The DPCS stated theres nothing before that to print out. The DPCS stated its her responsibility to ensure all patients are receiving what the care and services were ordered for them by the MD and this was not done for Patient 9. During a review of the agencys policy entitled ";Missed Visits" dated April 2020 it indicated missed visits will be communicated to the interdisciplinary group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record.

Based on interview, and record review, Hospice (specialized care provided to terminally ill [patients who have six months or less to live] patients) Agency 1 (HA 1- agency providing care to terminally ill patients) failed to ensure the Condition of participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) regarding Core Services was met when the Director of Patient Care Services (DPCS) failed to direct and supervise the nursing care for three of fourteen sample patients (Patient 1, Patient 9, and Patient 11) by: --- 1. Failing to ensure the HAs licensed nurses (Licensed Vocational Nurse [LVN], Registered Nurse [RN]) conducted an initial comprehensive assessment (an assessment used to evaluate a patient's overall health, including identifying the patients need for hospice care) for one of 14 sampled patients (Patient 1) for certification period 2/5/2024 to 5/4/2024, 5/5/2024 to 8/2/2024, 8/3/2024 to 10/1/2024, and 10/2/2024 to 11/30/2024. Patient 1s start of care (SOC) was on 2/5/2024. 2. Failing to ensure one of 14 sampled patients (Patient 1) did not receive hospice services by two different hospice agencies. 3. Failing to ensure one of 14 sampled patients (Patient 9) had a comprehensive assessment and an updated nursing assessment for certification period 8/27/2024 to 10/25/2024 and 10/26/2024 to 12/24/2024. Patient 9s SOC was on 12/31/2023. 4. Failing to ensure one of 14 sampled patients (Patient 11) plan of care (POC-a patients assessed health or care needs) was updated when a change of condition (COC- significant alteration in a patient's health or functioning that could lead to complications or death if left untreated) occurred for the first certification period (the first period a patient is determined to meet the level for hospice care) beginning on 4/9/2024; second certification period (the second period a patient is determined to meet the level for hospice care) beginning on 4/24/2024; and third certification period (the third period a patient is determined to meet the level for hospice care) beginning on 5/17/2024. The non-compliance resulted in the HA providing care without assessing and identifying the needs of Patient 1 and Patient 9 that could result to hospitalization and death for Patient 1 and Patient 9; and resulted in the worsening of Patient 11s pressure injury (PI-injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) to the sacrum (he large, triangle-shaped bone in the lower spine), right buttocks, and bilateral (both) feet. Patient 11 was hospitalized for worsening pressure injuries and was noted to have maggots (worms) on the PI wounds to Patient 11s feet. (Refer to L591). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (written law) compliance with Federal Regulations for Core Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive Medicare hospice benefits. 1. The HA failed to ensure post death bereavement services were conducted for one of fourteen sample selected patients (Patient 5) family/caregiver. (Refer to L 596). 2. The HA failed to ensure the Director of Patient Care Services (DPCS) failed to direct and supervise the nursing care for three of fourteen sample selected patients (Patient 1, Patient 9, and Patient 11) by: 1. Failing to ensure the HAs licensed nurses (Licensed Vocational Nurse [LVN], Registered Nurse [RN]) conducted an initial comprehensive assessment (an assessment used to evaluate a patient's overall health, including identifying the patients need for hospice care) for one of 14 sampled patients (Patient 1) for certification period 2/5/2024 to 5/4/2024, 5/5/2024 to 8/2/2024, 8/3/2024 to 10/1/2024, and 10/2/2024 to 11/30/2024. Patient 1s start of care (SOC) was on 2/5/2024. 2. Failing to ensure one of 14 sampled patients (Patient 1) did not receive hospice services by two different hospice agencies. 3. Failing to ensure one of 14 sampled patients (Patient 9) had a comprehensive assessment and an updated nursing assessment for certification period 8/27/2024 to 10/25/2024 and 10/26/2024 to 12/24/2024. Patient 9s SOC was on 12/31/2023. 4.Failing to ensure one of 14 sampled patients (Patient 11) plan of care (POC-a patients assessed health or care needs) was updated when a change of condition (COC- significant alteration in a patient's health or functioning that could lead to complications or death if left untreated) occurred for the first certification period (the first period a patient is determined to meet the level for hospice care) beginning on 4/9/2024; second certification period (the second period a patient is determined to meet the level for hospice care) beginning on 4/24/2024; and third certification period (the third period a patient is determined to meet the level for hospice care) beginning on 5/17/2024. The non-compliance resulted in the HA providing care without assessing and identifying the needs of Patient 1 and Patient 9 that could result to hospitalization and death for Patient 1 and Patient 9; and resulted in the worsening of Patient 11s pressure injury (PI-injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) to the sacrum (he large, triangle-shaped bone in the lower spine), right buttocks, and bilateral (both) feet. Patient 11 was hospitalized for worsening pressure injuries and was noted to have maggots (worms) on the PI wounds to Patient 11s feet. (Refer to L591). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (written law) compliance with Federal Regulations for Core Services, and Quality of Care to ensure highest quality health care is provided to patients assessed to receive Medicare hospice benefits.

Based on interview, and record review, Hospice (specialized care provided to terminally ill [patients who have six months or less to live] patients) Agency 1s (HA 1, agency providing care to terminally ill patients) Director of Patient Care Services (DPCS) failed to direct and supervise the nursing care for three of fourteen sample patients (Patient 1, Patient 9, and Patient 11) by: 1. Failing to ensure the HAs licensed nurses (Licensed Vocational Nurse [LVN], Registered Nurse [RN]) conducted an initial comprehensive assessment (an assessment used to evaluate a patient's overall health, including identifying the patients need for hospice care) for one of 14 sampled patients (Patient 1) for certification period 2/5/2024 to 5/4/2024, 5/5/2024 to 8/2/2024, 8/3/2024 to 10/1/2024, and 10/2/2024 to 11/30/2024. Patient 1s start of care (SOC) was on 2/5/2024. 2. Failing to ensure one of 14 sampled patients (Patient 1) did not receive hospice services by two different hospice agencies. 3. Failing to ensure one of 14 sampled patients (Patient 9) had a comprehensive assessment and an updated nursing assessment for certification period 8/27/2024 to 10/25/2024 and 10/26/2024 to 12/24/2024. Patient 9s SOC was on 12/31/2023. 4. Failing to ensure one of 14 sampled patients (Patient 11) plan of care (POC-a patients assessed health or care needs) was updated when a change of condition (COC- significant alteration in a patient's health or functioning that could lead to complications or death if left untreated) occurred for the first certification period (the first period a patient is determined to meet the level for hospice care) beginning on 4/9/2024; second certification period (the second period a patient is determined to meet the level for hospice care) beginning on 4/24/2024; and third certification period (the third period a patient is determined to meet the level for hospice care) beginning on 5/17/2024. The non-compliance resulted in the HA providing care without assessing and identifying the needs of Patient 1 and Patient 9 that could result to hospitalization and death for Patient 1 and Patient 9; and resulted in the worsening of Patient 11s pressure injury (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) to the sacrum (he large, triangle-shaped bone in the lower spine), right buttocks, and bilateral (both) feet. Patient 11 was hospitalized for worsening pressure injuries and was noted to have maggots (worms) on the Patient 11s feet PI wounds. On 11/2/2024, at 1:15 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused, or likely to cause, serious injury, harm impairment, or death to a patient), in the presence of the agencys Director of Patient Care Services (DPCS), Office Manager (OM), Office Saff (OS), Quality Assurance (QA), related to the failure to ensure the Director of Patient Care Services directed and supervised the nursing care for three of fourteen sample patients (Patient 1, Patient 9, and Patient 11) ,which resulted in the Hospice Agency providing care (Patient 1, Patient 9, and Patient 11) without assessing and identifying the needs of the patients that could result to hospitalization and death. On 11/2/2024, at 1:45pm, the Survey team completed the survey tasks and conducted an exit conference with the DPCS, Office manager, and the Quality Assurance nurse with the IJ situation not removed. The HA did not submit an IJ removal plan. --- 2. During a review of Patient 9s Personal Information sheet, the Personal Information sheet indicated a SOC date of 12/31/2023 with a primary diagnosis of hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 9s Re-Cert Assessment, (recertification assessment), dated 8/22/2024, the Re-Cert indicated that section ";Body System (Head-to-toe)" assessment sections were blank. Body System (Head-to-toe [a comprehensive physical examination that evaluates a patient's overall health status, needs, and goals)" assessment sections were blank. The Comprehensive Nursing Assessment indicated sections: ";Imminently Dying, Environmental/Safety, Personal Care and Support Needs, Teaching Needs, Psychosocial Screening, Spiritual Screening, Bereavement Screening, and Referrals were blank and did not indicate who the author was. During a review of Patient 9s Updated Assessment, dated 8/8/2024, the Updated Assessment indicated the form was blank. During a review of Patient 9s Updated Assessment, dated 8/22/2024, the Updated Assessment indicated the form was blank. During a review of Patient 9s Updated Assessment, dated 9/5/2024, the Updated Assessment, indicated the form was blank. During a record review of Patient 9s Updated Assessment, dated 09/19/2024, the Updated Assessment indicated the form was blank. During an interview on 11/1/2024, at 3:05 pm with the DPCS, the DPCS stated Patient 9s Updated Assessments dated 8/8/2024, 8/22/2024, 9/5/2024, and 9/19/2024, there were not complete including: environmental, mobility, intravenous (IV, under the vein) assessments for each date provided. The DPCS stated she (DPCS) is responsible to check all the patients charts and to ensure the updated assessments were complete which were not done. During an interview on 11/1/2024, at 3:05 pm, with the DPCS, the DPCS stated she did not know the reason why the comprehensive assessment was not done for Patient 9. Findings: 1. During a review of Patient 1s Personal Information sheet, the Personal Information sheet indicated a SOC date of 2/5/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-difficulty breathing cause by several lung issues). During a review of Patient 1s undated History of Nursing Assessment, the History of Nursing Assessment indicated there were five entries made dated 2/5/2024, 4/15/2024, 4/29/2024, 6/10/2024 and 6/24/2024, with a red ";X" (the visit was scheduled and not conducted) under each dates status indicating.... During a review of Patient 1s Comprehensive Nursing Assessment, dated 2/5/2024, the Comprehensive Nursing Assessment indicated section ";Body System (Head-to-toe [a comprehensive physical examination that evaluates a patient's overall health status, needs, and goals)" assessment sections were blank. The Comprehensive Nursing Assessment indicated sections: ";Imminently Dying, Environmental/Safety, Personal Care and Support Needs, Teaching Needs, Psychosocial Screening, Spiritual Screening, Bereavement Screening, and Referrals were blank and did not indicate who the author was. During a review of Patient 1s Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated from 2/5/2024 to 5/4/2024, the Certification for Hospice Benefit indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". The form also indicated it was not signed by Medical Director 1 (MD1). During a review of Patient 1s undated History of Visit Notes, the History of Visit Note indicated six entries dated 3/13/2024, 3/27/2024, 4/13/2024, 4/27/2024, 5/11/2024, and 5/25/2024 with a red ";X" on their status. During a review of Patient 1s Visit Note LVN (License Vocational Nurse), dated 4/13/2024, Visit Note LVN indicated form was blank. During a review of Patient 1s Updated Assessment (an assessment of the patients current status), dated 4/15/2024, the Updated Assessment indicated the form was blank. During a review of Patient 1s Visit Note LVN dated 4/27/2024, the Visit Note LVN indicated the form was blank. During a review of Patient 1s Updated Assessment dated 4/29/2024, the Updated Assessment indicated the form was blank. During a review of Patient 1s Visit Note LVN dated 5/11/2024, the Visit Note LVN did not indicate who the author was. During a review of Patient 1s Updated Assessment dated 6/10/2024, the Updated Assessment indicated the form was blank. During a review of Patient 1s Updated Assessment dated 6/24/2024, the Updated Assessment indicated the form was blank. During a review of Patient 1s Local Coverage Determination (LCD) Hospice Eligibility Determination, dated 6/24/2024, the LCD indicated ";Patient Does not qualify per LCD guidelines." During a review of Patient 1s Updated Assessment dated 6/24/2024, the Updated Assessment indicated the form was blank. During a review of Patient 1s POC Summary dated as of 10/29/2024, the POC Summary indicated the section for allergies, functional limitation Activities of Daily Living (ADL- bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) need, mental status, disaster triage (the process of prioritizing patients for treatment), and treatment were left blank. During a concurrent interview and record review on 11/1/2024, at 2:42 p.m. with the DPCS, reviewed Patient 1s Comprehensive assessment, dated 2/5/2024. The DPCS stated Patient 1s Comprehensive Assessment was missing a head-to-toe assessment, psychosocial screening, spiritual screening, bereavement screening were not complete. The DPCS stated Patient 1s Comprehensive Assessment was also missing the authors name and signature. The DPCS stated the nursing assessments were important because the patient needs were based on the assessment. The DPCS stated Patient 1 had the potential to miss out on interventions or treatments needed. The DPCS stated Patient 1s assessments were missing Patient 1s ";baseline," (medical condition at the time of admission), which was ";key," (important) to Patient 1s care. During an interview on 11/1/2024, at 2:42 pm, with the DPCS, the DPCS stated she did not know the reason why the comprehensive assessment was not done for Patient During a concurrent interview and record review on 11/1/2024, at 2:55 p.m., with the DPCS, reviewed Patient 1s undated POC Summary dated as of 10/29/2024. The DPCS stated the POC (plan of care) Summary was not complete. The DPCS stated that Patient 1s POC Summary should have been completed by the HAs Registered Nurse (RN).The DPCS stated that there was no comprehensive assessment done for Patient 1. The DPCS stated it was impossible to formulate Patient 1s POC without an RN assessment. During a review of Patient 1s medical record form titled Face to Face (F2F) Visit Notes List undated, the F2F Visit Notes List indicated there were no entries made. During a review of Patient 1s Physicians Certification for Hospice Benefit – Certification #3: Re-certification Statement for next 60-day period" dated from 8/3/2024 to 10/1/2024, the Physicians Certification for Hospice Benefit indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." The Physicians Certification for Hospice Benefit was left blank and not signed by Medical Director 1 (MD1). During a review of Patient 1s Physicians Certification for Hospice Benefit – Certification #4: Re-certification Statement for next 60-day period" dated from 10/2/2024 to 11/30/2024, indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." The Physicians Certification for Hospice Benefit indicated it was blank and not signed by MD1. During a review of the HAs email regarding Patient 1s provided by the DPCS, the DPCS stated the printed email was sent by their billing department dated 7/9/2024. The DPCS stated the form indicated Patient 1 had overlapping hospice services with another hospice agency 2 (HA2). During a record review of HAs form titled ";Current Census" undated, indicated Patient 1 was a current HA patient of HA 1 with a start of care date of 2/5/2024. The Current Census indicated section end of care date was blank. During a record review on 10/30/2024, at 12:15 p.m., of Patient 1s Communication Log, the Communication Log did not indicate there was an entry made on 7/9/2024. During an interview on 10/31/2024, at 12:30 p.m., with the DPCS, the DPCS stated the patient assessments were critical. The DPCS stated that the patients (in general) initial and comprehensive assessments should be completed within 24 to 48 hours of SOC. The DPCS stated during the initial and comprehensive assessment, the patients were provided with the explanations of the hospice benefits, and education on the HAs philosophy. The DPCS stated patients are to receive a nursing recertification assessment 90 days from the SOC, and every 60 days after that. The DPCS stated patients need to be assessed and reassessed to make sure they (patients) qualify for hospice services. During an interview on 10/31/2024, at 1:25 p.m., with DPCS, DPCS stated a patients individualized plan of care serves as a guide for visiting nurses. During an interview on 10/31/2024, at 2:45 p.m., with the HAs Electronic Medical Record (EMR) systems representative (RP1), RP1 stated that a red ";X" under the status column indicates that a visit has been created, but it has not been submitted for review to the QA (quality assurance) staff. RP1 stated the yellow triangle with exclamation mark in it under the status sections indicates it has been submitted for review and is currently under review. During a concurrent interview and record review on 11/1/2024, at 2:42 p.m., with the DPCS, reviewed Patient 1s Electronic Medical Record (EMR) medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1", Physicians Certification for Hospice Benefit – Certification #2", and ";Physicians Certification for Hospice Benefit – Certification #4". DPCS stated that Patient 1s Physician Certification for Hospice Benefit Certification #1, #2, and #4 were not signed by MD1. DPCS stated the HA1 should have discharged Patient 1 because Patient 1 was receiving hospice services from HA2 on 7/9/2024. The DPCS stated there was a communication note documented on 7/9/2024 to inform the Department of overlapping issues and the DPCS did not follow up on the matter. The DPCS stated she (DPCS) did not know what happened, and how come Patient 1 was still receiving hospice services through HA1. During a concurrent interview and record review on 11/1/2024, at 2:42 p.m. with the DPCS, reviewed Patient 1s Comprehensive assessment, dated 2/5/2024. The DPCS stated Patient 1s Comprehensive Assessment was missing a head-to-toe assessment, psychosocial screening, spiritual screening, bereavement screening were not complete. The DPCS stated Patient 1s Comprehensive Assessment was also missing the authors name and signature. The DPCS stated the nursing assessments were important because the patient needs were based on the assessment. The DPCS stated Patient 1 had the potential to miss out on interventions or treatments needed. The DPCS stated Patient 1s assessments were missing Patient 1s ";baseline," (medical condition at the time of admission), which was ";key," (important) to Patient 1s care. During a concurrent interview and record review on 11/1/2024, at 2:55 p.m., with the DPCS, reviewed Patient 1s undated POC Summary dated as of 10/29/2024. The DPCS stated the POC (plan of care) Summary was not complete. The DPCS stated that Patient 1s POC Summary should have been completed by the HAs Registered Nurse (RN).The DPCS stated that there was no comprehensive assessment done for Patient 1. The DPCS stated it was impossible to formulate Patient 1s POC without an RN assessment. 2. During a review of Patient 9s Personal Information sheet, the Personal Information sheet indicated a SOC date of 12/31/2023 with a primary diagnosis of hypertensive heart disease without heart failure (heart problems that occur because of high blood pressure that is present over a long time). During a review of Patient 9s Re-Cert Assessment, (recertification assessment), dated 8/22/2024, the Re-Cert indicated that section ";Body System (Head-to-toe)" assessment sections were blank. Body System (Head-to-toe [a comprehensive physical examination that evaluates a patient's overall health status, needs, and goals)" assessment sections were blank. The Comprehensive Nursing Assessment indicated sections: ";Imminently Dying, Environmental/Safety, Personal Care and Support Needs, Teaching Needs, Psychosocial Screening, Spiritual Screening, Bereavement Screening, and Referrals were blank and did not indicate who the author was. During a review of Patient 9s Updated Assessment, dated 8/8/2024, the Updated Assessment indicated the form was blank. During a review of Patient 9s Updated Assessment, dated 8/22/2024, the Updated Assessment indicated the form was blank. During a review of Patient 9s Updated Assessment, dated 9/5/2024, the Updated Assessment, indicated the form was blank. During a record review of Patient 9s Updated Assessment, dated 09/19/2024, the Updated Assessment indicated the form was blank. During an interview on 11/1/2024, at 3:05 pm with the DPCS, the DPCS stated Patient 9s Updated Assessments dated 8/8/2024, 8/22/2024, 9/5/2024, and 9/19/2024, there were not complete including: environmental, mobility, intravenous (IV, under the vein) assessments for each date provided. The DPCS stated she (DPCS) is responsible to check all the patients charts and to ensure the updated assessments were complete which were not done. During an interview on 11/1/2024, at 3:05 pm, with the DPCS, the DPCS stated she did not know the reason why the comprehensive assessment was not done for Patient 9.

Based on interview and record review, the Hospice Agency (HA) failed to ensure post death bereavement services were provided for one of fourteen sample selected patients (Patient 5) family/caregiver. This failure had the potential to result in Patient 5s family/caregiver being left with feelings of grief, separation anxiety, guilt, and loneliness by not providing a professional counselor trained in grief psychology. --- During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 5/20/2024 and an end of care date of 9/22/2024 with a primary diagnosis of Alzheimers Disease, unspecified (progressive memory loss). During a record review of Patient 5s undated, medical record form titled ";Post-Death Bereavement Support" indicated there was nothing documented. During a record review of Patient 5s undated, medical record form titled ";History of Bereavement Letters" indicated there was nothing documented. During a record review of Patient 5s undated, medical record form titled ";History of Post-Death Bereavement Assessment" indicated there was nothing documented. During a concurrent interview and record review on 11/1/2024 at 12:15 p.m. with the Director of Patient Care Services (DPCS) of Patient 5s Electronic Medical Record (EMR) medical record titled ";Bereavement," the DPCS stated the HA is unaware if Patient 5s family/caregiver received post death bereavement services because there was no documentation stating that they did. The DPCS stated that post death bereavement services are to be offered after a patient passes to assess the family/caregiver social needs. The DPCS stated Patient 5s family/caregiver might be feeling lost and going through grief. The DPCS stated the HA needs to be made available to Patient 5s family/caregivers because post death bereavement services is part of their services. During an interview on 10/31/2024 at 2 p.m. with the DPCS, the DPCS stated patients bereavement assessment starts within five days of their start of care by the Spiritual Counselor (SC) or the Medical Social Worker (MSW) to evaluate the spiritual needs of the patient and their family/caregiver to prepare them for the patients expected decline. The DPCS stated that families/caregivers might have unresolved conflicts and resentments, and that is why they ";need to have an ear to hear them and they can pour their hearts out." The DPCS stated after a patient passes the SC reaches out to the family either the same day or the next to offer their services. The DPCS stated, ";It is part of our services to reach out to them because it is a very emotional, they need someone to speak to and someone to talk to." During an interview on 11/1/2024 at 1:06 p.m. with the SC, the SC stated he was unable to log into the HAs EMR system to discuss specific patients. The SC stated he takes care of the patient and their family's emotional needs by conducting patients initial and bereavement assessments. During a record review of the HAs form titled ";Bereavement Assessment" revised 4/2020, the form indicated, ";The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of the patients death as part of the comprehensive assessment. After death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment."

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

Based on interview and record review, the Hospice Agency (HA) failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) reviewed patients clinical information to determine hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care criteria is met and/or provide an initial written certification that the patient had six months or less to live if the illness runs its normal course for two of fourteen sample patients (Patient 1 and Patient 12). These deficient practices resulted in the hospice medical director and/or the designee certifying patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses. It also resulted in patients not being certified by a medical doctor for hospice care, which can result in a lack of and inappropriate care being provided to the patients. --- During an interview on 10/31/2024 at 1:25 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated a CTI (certification of terminal illness is a document that is filled out and signed by a physician certifying a patient is considered terminally ill and has a life expectancy of six months or less if their illness progresses normally) was the attestation of the Medical Director 1 (MD) that the patients have 6 months to live if the terminal diagnosis runs its normal course. The DPCS stated that a CTI should be completed within 24 hours after the initial and at every recertification nursing assessment to validate that the patient is appropriate and can continue to receive hospice services. The DPCS stated that the LCD (Local Coverage of Determination is a document that provides guidelines on determining hospice benefit eligibility) was the determining factor to determine if a patient meets hospice criteria. The DPCS stated the HA uses the LCD as a guide. During an interview on 11/1/2024 at 2:07 p.m. with the MD1, MD1 stated being unable to log into the HAs Electronic Medical Record (EMR) system to discuss specific patients. MD1 stated he completes patients CTI form via ";face time" when the admitting nurse is assessing the patient within 4-5 days of a patient start of care. MD1 stated if a patient CTI is not in their EMR it indicated ";sloppy paperwork" and that most likely it was not documented and was missed. MD1 stated ";we are bad secretaries". MD1 stated patients CTIs get signed by him when the HA staff remind him to sign. MD1 stated he conducts face to face patient assessment on occasions and via telemedicine. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 2/5/2024 with a primary diagnosis of chronic obstructive pulmonary disease (difficulty breathing cause by several lung issues). During a record review of Patient 1s medical record form titled ";Certification List" undated, indicated certificate #1, #2, #3, and #4s status was pending. During a record review of Patient 1s medical record form title ";LCD Hospice Eligibility Determination" indicated the last LCD was documented on 6/24/2024. The form also indicated ";Patient does not qualify per LCD Guidelines". During a concurrent interview and record review on 11/1/2024 at 2:42 p.m. with the DPCS of Patient 1s medical record form titled ";Physicians Certification for Hospice Benefit" dated from 2/5/2024 to 5/4/2024, the DPCS stated Patient 1s Physicians Certification for Hospice Benefit form was not completed, therefore Patient 1 had not been certified by a physician to receive hospice care. The DPCS stated not knowing if Patient 1 qualified for hospice care and needed to follow up on Patient 1s status. Lastly, the Physicians Certification for Hospice Benefit indicated it was not signed by a physician. An attempt to contact Patient 1 was made on 11/1/2024 at 1:42 p.m., without success. An attempt to contact Patient 1s Family Member/Authorized Representative (FAM1) was made on 11/1/2024 at 2:43 p.m., without success. 2. A record review of Patient 12s Personal Information sheet indicated a start of care date on 6/7/2024, with a terminal diagnosis of Multiple Sclerosis (a disease that affects the central nervous system, including the brain and spinal cord). The record also indicated an end of care date of 10/20/2024, for the reason of being hospitalized. A record review of the Patient 12s ";CTI", for certification period 6/7/2024 to 9/4/2024, indicated a documented entry under the section where the doctor is supposed to document titled, ";physician narrative". Further review of the record did not indicate the document was signed by the doctor. During a concurrent interview and record review on 11/2/2024, at 1:05 p.m., the DPCS reviewed Patient 12s record titled, ";Audit Log" (a document that indicates what changes, additions, and entries were made in the electronic medical record), dated 6/7/2024 to 11/2/2024. The record indicated the DPCS had entered the physician narrative for the certification of terminal illness and not MD 1. When asked why the DPCS had documented the certification of terminal illness, the DPCS did not offer a response. During a record review of the HAs form titled ";Certification of Terminal Illness" revised 4/2020, the form indicated, ";At the time a patient and family/caregiver choose hospice care, the hospice Medial Director and the patients attending physician, if any, will certify the patients terminal illness. Patient who elects the hospice Medicare 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 attending physician and the hospice Medical Director. Hospice services will be provided in tow (2) 90-day periods and an unlimited number of 60-day periods if the patient is recertified at the beginning of each benefit period. Both the attending physicians and Medical Director signed and dated initial certification forms must be on file prior to billing the first claim. A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. All physician certification and authorization for hospice services and the certification of terminal illness forms will e filed in the patients permanent clinical record." During a record review of the HAs form titled ";Contents of Clinical Record" revised 4/2020, the form indicated, ";The clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. The following information will be available in the clinical record as applicable to care and services provided: X. Certification and recertification(s) of terminal illness including physician narrative and face to face encounter as needed. Each entry will be dated and signed, including title and credentials, by the person providing the care/service. During a record review of the HAs form titled ";Comprehensive Assessment" revised 4/2020, the form indicated, ";The Clinical Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the medical director and/or physician designee conducted, reviewed, and verified the patients clinical information to determine the patients need for recertification of terminal illness for continued hospice care and services for eight of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 12, and Patient 14). 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 to result in the patients not receiving appropriate healthcare services that could affect their quality of life. --- 5. During a review of patient 8s ";face sheet" it indicated he was admitted to the hospice agency on 6/4/24 with a primary diagnosis of cerebral infarction (blockage in the blood vessels supplying blood to the brain). During a review of patient 8s ";POC/IDG review" under frequency of visits, it indicated MSW visits every recert, Spiritual counselor visits every recert, SN visits 1/week, and RN visits 1/ 2 weeks. During a review of patient 8s ";CTI" (certification list) certification #2 9/2/24 to 11/30/24, it indicated that MD did not sign off and complete the documentation for this document. During an interview on 11/1/24 at 2:10pm with the medical director, he stated that he signs the certification of terminal illness (CTI) forms for each patient when directed by the nursing supervisor, he stated if its not signed then he was never approached by nursing supervisor to sign it. He stated the signatures on the IDT note would indicate that whoever signed it, was there and participated in the discussion regarding that patient. During an interview on 11/1/24 at 3:05pm with the DPCS, she stated that certification #2 dated 9/2/24 to 11/30/24 for patient 8 should have been signed by the MD after that period was over and it was not. She further stated that it is her responsibility to ensure that all patients are receiving care and services ordered by the MD and it was not done here. 6. During a review of patient 9s ";face sheet" it indicated he was admitted to the hospice agency on 12/31/23 with a primary diagnosis hypertensive heart disease without heart failure ((heart problems that occur because of high blood pressure that is present over a long time). During a review of patient 9s ";POC/IDG review" under the frequency of visits, it indicated she had CHHA visits 2/week, SN 1/week, MSW visits 1/recertification, SC visits 1/recertification and RN visits 1/2 weeks. During a review of patient 9s ";CTI" (certification list) Certification #2 3/30/24 to 6/27/24, indicated that MD did not sign off and complete the documentation for this document. Certification #3 6/28/24 to 8/26/24, indicated that MD did not sign off and complete the documentation for this document. Certification #4 8/27/24 to 10/25/24, indicated that MD did not sign off and complete the documentation for this document. During an interview on 11/1/24 at 2:10pm with the medical director, he stated that he signs the certification of terminal illness (CTI) forms for each patient when directed by the nursing supervisor, he stated if its not signed then he was never approached by nursing supervisor to sign it. He stated the signatures on the IDT note would indicate that whoever signed it, was there and participated in the discussion regarding that patient. During an interview on 11/1/24 at 3:05pm with the DPCS, she stated that certification #2 dated 9/2/24 to 11/30/24, Certification #3 6/28/24 to 8/26/24, and Certification #4 8/27/24 to 10/25/24 for patient 9 should have been signed by the MD after that period was over and it was not. She further stated that it is her responsibility to ensure that all patients are receiving care and services ordered by the MD and it was not done here. During a review of the agency policy entitled ";Certification of Terminal Illness" dated April 2020 indicated this policy is to ensure physician certification of terminal illness and authorization for hospice services in accordance with applicable state and federal regulations and payer requirements. During an interview on 10/31/2024 at 1:25 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated a CTI (certification of terminal illness is a document that is filled out and signed by a physician certifying a patient is considered terminally ill and has a life expectancy of six months or less if their illness progresses normally) was the attestation of the Medical Director 1 (MD) that the patients have 6 months to live if the terminal diagnosis runs its normal course. The DPCS stated that a CTI should be completed within 24 hours after the initial and at every recertification nursing assessment to validate that the patient is appropriate and can continue to receive hospice services. The DPCS stated that the LCD (Local Coverage of Determination is a document that provides guidelines on determining hospice benefit eligibility) was the determining factor to determine if a patient meets hospice criteria. The DPCS stated the HA uses the LCD as a guide. During an interview on 11/1/2024 at 2:07 p.m. with the MD1, MD1 stated being unable to log into the HAs Electronic Medical Record (EMR) system to discuss specific patients. MD1 stated he completes patients CTI form via ";face time" when the admitting nurse is assessing the patient within 4-5 days of a patient start of care. MD1 stated if a patient CTI is not in their EMR it indicated ";sloppy paperwork" and that most likely it was not documented and was missed. MD1 stated ";we are bad secretaries". MD1 stated patients CTIs get signed by him when the HA staff remind him to sign. MD1 stated he conducts face to face patient assessment on occasions and via telemedicine. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 2/5/2024 with a primary diagnosis of chronic obstructive pulmonary disease (difficulty breathing cause by several lung issues). During a record review of Patient 1s medical record form title ";LCD Hospice Eligibility Determination" indicated the last LCD was documented on 6/24/2024. The form also indicated ";Patient does not qualify per LCD Guidelines". During a record review of Patient 1s medical record form titled ";Certification List" undated, indicated certificate #1, #2, #3, and #4s status was pending. During a record review of Patient 1s medical record form titled ";Physicians Certification for Hospice Benefit" dated from 8/3/2024 to 10/1/2024, indicated the form was left blank and did not have a physicians signature. During a record review of Patient 1s medical record form titled ";Physicians Certification for Hospice Benefit" dated from 10/2/2024 to 11/30/2024, indicated the form was left blank and did not have a physicians signature. During a concurrent interview and record review on 11/1/2024 at 2:42 p.m. with the DPCS of Patient 1s medical record forms titled ";Physicians Certification for Hospice Benefit" dated from 8/3/2024 to 10/1/2024, and 12/2/2024 to 11/30/2024, the DPCS stated Patient 1s Physicians Certification for Hospice Benefit forms were not completed, therefore Patient 1 had not been certified by a physician for hospice care. The DPCS stated not knowing if Patient 1 qualified for hospice care and needed to follow up on status. The DPCS stated the HA continues to provide hospice services to Patient 1. An attempt to contact Patient 1 was made on 11/1/2024 at 1:42 p.m., without success. An attempt to contact Patient 1s Family Member/Authorized Representative (FAM1) was made on 11/1/2024 at 2:43 p.m., without success. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 3/15/2023 with a primary diagnosis of hemiplegia (one side of body weakness) following unspecified cerebrovascular disease affecting left dominant side. During a record review of Patient 2s medical record form titled ";Certification List" undated, indicated certificate #11 dated from 10/5/2024 to 12/3/2024 status is pending. During a record review of Patient 2s medical record form titled ";Physicians Certification for Hospice Benefit" dated from 10/5/2024 to 12/3/2024, indicated sections ";face to face narrative and certifying physician narrative" were left blank. The Physicians Certification for Hospice Benefit also indicated it was not signed by a physician. During a record review of Patient 2s EMR medical record form title ";F2F (face to face – a face to face assessment made by a physician) visit notes list" indicated there was one physician face to face assessment dated 6/13/2023. During a record review of Patient 2s EMR medical record form title ";LCD Hospice Eligibility Determination" dated 10/9/2024, indicated ";Patient does not qualify per LCD Guidelines". During a concurrent interview and record review on 10/31/2024 at 2:30 p.m. with the DPCS of Patient 2s EMR, medical record form titled ";Physicians Certification for Hospice Benefit" dated from 10/5/2024 to 12/3/2024, the DPCS stated Patient 2s CTI should have been filled out and signed by the MD1 no later than 10/5/2024. The DPCS stated it was the responsibility of MD1 to fill out and sign Patient 2s CTI. The DPCS stated Patient 2 has one documented face to face visit dated 6/13/2023. The DPCS stated Patient 2 has several LCDs missing. During an interview on 10/30/2024 at 1:20 p.m. with Patient 2s Family Member 5 (FAM5), FAM5 stated Patient 2 lives with her. FAM5 stated Patient 2 nor her have been told by a physician that Patient 2 has six months or less to live. FAM5 stated the HA ";gave" them permission to take Patient 2 to a hospital in May 2023. 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 4/21/2023 with a primary diagnosis of Alzheimers Disease (progressive memory loss) with early onset. During a record review of Patient 3s EMR medical record form title ";Certification List" indicated CERT#9 dated from 10/12/2024 to 12/10/2024, status was pending. During a record review of Patient 3s medical record form titled ";Physicians Certification for Hospice Benefit" dated from 10/12/2024 to 12/10/2024, indicated sections ";face to face narrative and certifying physician narrative" were left blank. Patient 3s Physicians Certification for Hospice Benefit indicated it was not signed by a physician. During a record review of Patient 3s EMR medical record form title ";F2F Visit Notes List" indicated there was only one entry made on 5/7/24 which had a red ";X" documented under ";status". During a record review of Patient 3s medical record form titled ";F2F Visit Notes list" dated 5/7/2024, indicated the form was left blank. During a concurrent interview and record review on 10/31/2024 at 3:45 p.m. with the DPCS of Patient 3s EMR medical record form titled Physicians Certification for Hospice Benefit, the DPCS stated Patient 3s Physicians Certification for Hospice Benefit dated from 10/12/2024 to 12/10/2024, was not completed. The DPCS stated Patient 3 was receiving hospice services without MD1s attestation Patient 3 required hospice services. The DPCS stated Patient 3 did not have documented certification to continue hospice services. During a concurrent interview and record review on 10/31/2024 at 3:45 p.m. with the DPCS of Patient 3s EMR medical record form titled F2F Visit Note dated 5/7/2024, the DPCS stated Patient 3s F2F Visit Note was blank. The DPCS stated Patient 3s F2F Visit Notes should have been completed in August. An attempt to contact Patient 3 was made on 11/1/2024 at 1:47 p.m., without success. An attempt to contact Patient 3s Family Member 4 (FAM4) was made on 11/1/2024 at 1:48 p.m., without success. 4. During a record review of Patient 4s medical record form titled ";Personal Information" indicated a start of care date of 4/26/2024 with a primary diagnosis of cerebral infarct due to unspecified occlusion or stenosis of unspecified anterior cerebral artery (brain artery blockage). During a record review of Patient 4s medical record form titled ";Certification List" undated, indicated certificate #2 and 3s status was pending. During a record review of Patient 4s medical record form titled ";Physicians Certification for Hospice Benefit" dated from 7/25/2024 to 10/22/2024, indicated sections ";Physician Narrative, Face to Face Narrative, and Certifying Physician Narrative" were left blank. Lastly, the form also indicated it was not signed by a physician. During a record review of Patient 4s medical record form titled ";Physicians Certification for Hospice Benefit" dated from 10/23/2024 to 12/21/2024, indicated sections ";Physician Narrative, Face to Face Narrative, and Certifying Physician Narrative" were left blank. Lastly, the form also indicated it was not signed by a physician. During a record review of Patient 4s medical record form titled ";F2F Visit Notes List" indicate there were no entries made. During a record review of Patient 4s medical record form title ";LCD Hospice Eligibility Determination" indicated the last LCD was documented on 10/25/2024. The form also indicated ";Patient does not qualify per LCD Guidelines". During a concurrent interview and record review on 11/1/2024 at 10:37 p.m. with the DPCS of Patient 4s EMR medical record form titled ";Physicians Certification for Hospice Benefit" dated from 7/25/2024 to 10/22/2024 and 10/23/2024 to 12/21/2024, the DPCS stated Patient 4s was currently in the 3rd recertification period. The DPCS stated it was not signed by MD1. The DPCS stated MD1 needed to sign Patient 4s CTIs within two days of the start of the recertification period. The DPCS stated it was important that MD1 signed Patient 4s CTIs because it will attest Patient 4s is eligible to receive hospice services. The DPCS stated the HA was limiting Patient 4s in receiving other treatments, outside of hospice. During an interview on 11/1/2024 at 1:54 p.m. with Patient 4s Family Member 3 (FAM3), FAM3 stated she is Patient 4s power of attorney. FAM3 stated she has never met MD1. FAM3 stated Patient 4 last saw his primary physician in February 2024. FAM3 stated she has never been told by any physician that Patient 4 had six months or less to live. FAM3 stated Patient 4 does not have a terminal illness. 7. A record review of Patient 12s Personal Information sheet indicated a start of care date on 6/7/2024, with a terminal diagnosis of Multiple Sclerosis (a disease that affects the central nervous system, including the brain and spinal cord). The record also indicated an end of care date of 10/20/2024, for the reason of being hospitalized. A record review of Patient 12s record titled ";CTI", for the 3rd certification period beginning 9/5/2024, did not indicate a doctor had entered a narrative to certify the patient for hospice care, nor did it indicate a doctors signature. During an interview on 11/2/2024, at 12:25 p.m., the DPCS stated the signature of the doctor on the CTI form meant the doctor had reviewed the care of the patient and should be recertified for hospice care. 8. A record review of Patient 14s Personal Information sheet indicated a start of care date on 1/19/2024, with a terminal diagnosis of heart disease. During an interview on 10/30/2024, at 1:08 p.m., Patient 14s family member (FAM 7) stated Patient 14 was waiting for a surgery appointment for his hip. FAM 7 stated Patient 14 originally had surgery on January 2024 and screws were placed in his hip and leg. FAM 7 stated she did not know what hospice care was, Patient 14 was not terminal, and no doctor had informed FAM 7 and Patient 14 his life expectancy was 6 months or less to live if the disease took its normal course. During an interview on 11/2/2024, at 12:25 p.m., the DPCS stated she was not aware Patient 14 was going to have surgery. The DPCS stated surgery was considered seeing active treatment and Patient 14 should not be in hospice care. The DPCS stated the signature of the doctor on the CTI form meant the doctor had reviewed the care of the patient and should be recertified for hospice care. A record review of Patient 14s record titled, ";CTI", for certification period beginning 9/15/2024 to 11/13/2024 did not have a doctors narrative certifying the patient for hospice care, nor did it have a signature. A record review of Patient 14s record titled, ";CTI", for certification period beginning 7/17/2024 to 9/14/2024 did not have a doctors narrative certifying the patient for hospice care, nor did it have a signature. During a record review of the HAs form titled ";Certification of Terminal Illness" revised 4/2020, the form indicated, ";At the time a patient and family/caregiver choose hospice care, the hospice Medial Director and the patients attending physician, if any, will certify the patients terminal illness. Patient who elects the hospice Medicare 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 attending physician and the hospice Medical Director. Hospice services will be provided in two (2) 90-day periods and an unlimited number of 60-day periods if the patient is recertified at the beginning of each benefit period. Both the attending physicians and Medical Director signed and dated initial certification forms must be on file prior to billing the first claim. A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. All physician certification and authorization for hospice services and the certification of terminal illness forms will e filed in the patients permanent clinical record." During a record review of the HAs form titled ";Contents of Clinical Record" revised 4/2020, the form indicated, ";The clinical record will contain sufficient information to identify the patient, describe the patients problems and needs, justify care, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. The following information will be available in the clinical record as applicable to care and services provided: X. Certification and recertification(s) of terminal illness including physician narrative and face to face encounter as needed. Each entry will be dated and signed, including title and credentials, by the person providing the care/service. During a record review of the HAs form titled ";Comprehensive Assessment" revised 4/2020, the form indicated, ";The Clinical Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation on Clinical Records was met as follows: --- 1. The HA failed to ensure 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 seven of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 12, Patient 13, and Patient 14). (Refer to L679). 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 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 seven of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in unauthorized and inaccurate patient information or assessment to be entered in the patients clinical record that could affect the patients quality of care and well-being. --- During an interview on 10/31/2024 at 1:35 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the HA expected the visiting nurses to document their patients visit notes in the HAs Electronic Medical Record (EMR) within 24-48 hours after their visits. The DPCS stated that the patients visit notes served as proof that they were visited and received hospice services. The DPCS stated that the patients visit notes are used to communicate the patients current status in order to coordinate and collaborate the patients care. The DPCS stated that the nurses signature indicate that the patient was assessed by them. During an interview on 11/1/2024 at 2:07 p.m. with the Medical Director 1 (MD1), MD1 stated being unable to log into the HAs EMR system to discuss specific patients. MD1 stated having his own log in information for the HAs EMR, but he is unable to recall it and will have to call the HA because ";They have my log in information." 1. During a record review of Patient 1s medical record form titled ";Personal Information," the form indicated a start of care date of 2/5/2024 with a primary diagnosis of chronic obstructive pulmonary disease (difficulty breathing cause by several lung issues). A record review of Patient 1s medical record form titled ";Physicians Certification for Hospice Benefit" dated from 2/5/2024 to 5/4/2024, indicated it was not signed by a physician. During a record review of Patient 1s medical record form titled ";Physicians Certification for Hospice Benefit" dated from 8/3/2024 to 10/1/2024, indicated it was not signed by a physician. During a record review of Patient 1s medical record form titled ";Physicians Certification for Hospice Benefit" dated from 10/2/2024 to 11/30/2024, the certification indicated it was not signed by a physician. During a record review of Patient 1s medical record form title ";Visit Note LVN (License Vocational Nurse)" dated 5/11/2024, did not indicate who the author was. During a concurrent interview and record review on 11/1/2024 at 2:42 p.m. with the DPCS of Patient 1s EMR medical record form titled ";Comprehensive Nursing assessment" dated 2/5/2024, the DPCS stated Patient 1s comprehensive assessment form was missing the authors name and signature. 2. During a record review of Patient 2s medical record form titled ";Personal Information," the Personal information form indicated a start of care date of 3/15/2023, with a primary diagnosis of hemiplegia (one side of body weakness) following unspecified cerebrovascular disease affecting left dominant side. During a concurrent interview and record review, on 10/31/2024 at 2:30 p.m. with the DPCS of Patient 2s medical record form titled ";Updated Assessment" dated 10/9/2024, Patient 2s Updated Assessment did not indicate who the author was. The DPCS stated the author forgot to sign Patient 2s Updated Assessment. The DPCS stated the authors signature indicated the author attesting that he visited and assessed Patient 2. 3. During a record review of Patient 4s medical record form titled ";Personal Information" the form indicated a start of care date of 4/26/2024 with a primary diagnosis of cerebral infarct due to unspecified occlusion or stenosis of unspecified anterior cerebral artery (brain artery blockage). During a record review of Patient 4s undated, medical record form title ";History of Spiritual Assessment" indicated there were two assessments documented on 4/28/2024 and 7/21/2024. During a record review of Patient 4s medical record form title ";Spiritual Assessment" dated 7/21/2024, indicated the form was left blank. During a record review of Patient 4s medical record form title ";History of Psychosocial Assessment" indicated there were two entries made dated 4/29/2024 and 7/23/2024. During a concurrent interview and record review on 11/1/2024 at 10:37 a.m. with the DPCS of Patients 4s EMR medical record form titled ";Spiritual Assessment" dated 7/21/2024, the DPCS stated the form was left blank. The DPCS stated there was a Spiritual Assessment note documented on 7/21/2024, but that it was unknow when the Spiritual Counselor (SC) entered it. During a concurrent interview and record review on 11/1/2024 at 10:38 a.m. with the DPCS of Patients 4s undated, EMR medical record form titled ";History of Psychosocial Assessment" the DPCS stated there were three entries in Patient 4s EMR, the last note was dated on 10/21/2024. The DPCS stated it was unknown when the Medical Social Worker (MSW) entered that note dated 10/21/2024. 4. During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 5/20/2024 and an end of care date of 9/22/2024 with a primary diagnosis of Alzheimers Disease, unspecified (progressive memory loss). During a record review of Patient 5s medical record form titled ";Discharge Summary" dated 9/22/2024, did not indicate who the author was. During a concurrent interview and record review on 11/1/2024 at 10:38 a.m. with the DPCS of Patients 4s EMR medical record form titled ";Discharge Summary" dated 9/22/2024, the DPCS stated DPCS did not know who the author of the note was because there was no listed staffs name or their signature. The DPCS stated Patient 5s Discharge Summary was not complete. The DPCS stated the form needed to paint Patient 5s status and changes since the start of care date of 5/20/2024. 5. A record review of Patient 12s Personal Information sheet indicated a start of care date on 6/7/2024, with a terminal diagnosis of Multiple Sclerosis (a disease that affects the central nervous system, including the brain and spinal cord). The record also indicated an end of care date of 10/20/2024, for the reason of being hospitalized. A record review of the Patient 12s ";CTI", for certification period 6/7/2024 to 9/4/2024, indicated a documented entry under the section where the doctor is supposed to document, titled, ";Physician narrative". Further review of the record did not indicate the document was signed by the doctor. During an interview on 11/2/2024, at 12:25 p.m., the DPCS stated the signature of the doctor on the CTI form meant the doctor had reviewed the care of the patient and should be recertified for hospice care. During a concurrent interview and record review on 11/2/2024, at 1:05 p.m., the DPCS reviewed Patient 12s record titled, ";Audit Log" (a document that indicates what changes, additions, and entries were made in the electronic medical record), dated 6/7/2024 to 11/2/2024. The record indicated the DPCS had entered the physician narrative for the certification of terminal illness and not MD 1. When asked why the DPCS had documented the certification of terminal illness, the DPCS did not offer a response. A record review of Patient 12s record titled ";CTI", for the 3rd certification period beginning 9/5/2024, did not indicate a doctor had entered a narrative to certify the patient for hospice care, nor did it indicate a doctors signature. 6. A record review of Patient 13s Personal Information sheet indicated a start of care date on 8/5/2024, with a terminal diagnosis of heart failure (heart is unable to pump blood and oxygen to the body). During a concurrent interview and record review on 11/2/2024, at 12:34 p.m., the DPCS reviewed Patient 13s records titled ";POC/IDG." The following documentation was entered, but there was no signature from the author on the following dates: 10/18/24, No Registered Nurse (RN) signature. Nursing narrative present. 10/4/24, No RN signature. Nursing narrative present. 9/20/24, No RN signature. Nursing narrative present. No Spiritual Counselor (SC) signature present. Spiritual narrative entered. 9/6/24, No RN signature. Nursing narrative present. No SC signature present. Spiritual narrative entered. 8/23/24, No RN signature. Nursing narrative present. No SC signature present. Spiritual narrative entered. 8/5/24, No RN signature. Nursing narrative present. No SC signature present. Spiritual narrative entered. The DPCS stated a signature was required on the document to validate the RN and SC presence and participation in the meeting. The signature validated what was documented about the patient. 7. A record review of Patient 14s Personal Information sheet indicated a start of care date on 1/19/2024, with a terminal diagnosis of heart disease. During an interview on 11/2/2024, at 12:25 p.m., the DPCS stated the signature of the doctor on the CTI form meant the doctor had reviewed the care of the patient and should be recertified for hospice care. A record review of Patient 14s record titled, ";CTI" for the certification period beginning 9/15/2024 to 11/13/2024 did not have a doctors narrative certifying the patient for hospice care, nor did it have a signature. A record review of Patient 14s record titled, ";CTI", for the certification period beginning 7/17/2024 to 9/14/2024 did not have a doctors narrative certifying the patient for hospice care, nor did it have a signature. During a record review of the HAs form titled ";Contents of Clinical Record" revised 4/2020, the form indicated, ";The following information will be available in the clinical record as applicable to care and services provided: M. Signed and dated clinical notes. Each entry will be dated and signed, including title and credentials, by the person providing the care/service. Clinical records will be reviewed at least quarterly by qualified organization personnel to assure that documentation entered is reliable, timely, valid, and accurate." During a record review of the HAs form titled ";Person or entry Authentication" revised 4/2020, the form indicated, ";(HA) will use appropriate authentication methods to confirm that only properly authenticated and authorized persons or entities access ePHI. Appropriate access methods may include: H. digital signatures."