Every finding on record at Affinity Hospice LLC

Based on interview and record review, the HA failed to ensure skilled nurses conducted ongoing medication reconciliation on every visit for three of eight sampled patients (Patient 3, Patient 15, Patient 16). The deficient practice had the potential to result in patients being subject to medication error. --- During a review of Patient 3s admission record indicated a start of care (SOC) date of 5/5/2024, witha terminal diagnosis of end stage heart failure (a specific type of heart failure that occurs in the heart's left ventricle). During a review of Patient 3's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 5/5/2024, the POC indicated an order for the SN (skilled nurse) to provide skilled nursing visits oncea week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a concurrent home visit on 11/13/2024, at 11:30 a.m., with LVN 1 at the Skilled Nursing Facility (SNF) were patient 3 resides, Patient 3 was observed alert to person, place and time, sitting up in his bed. A review of Patient 3s Hospice Agencys(HA) medication profile and patient 3s Medication Administration Record (MAR) at the Skilled Nursing Facility (SNF) indicated the following discrepancies: SNF had an order for Morphine 20mg/ml. Give 0.25ml sublingual every 4 hrs.(Medication was not on Has Medication profile) Review of HAs Medication Profile had an order for Benadryl 6.25 mg/5ML (unit of measure)give 10 ML every 6 hrs, as needed for HIVES. Review of the SNFs MAR indicated Benadryl capsules 25MG. Give 2 capsules (50 mg) every 6 hours for HIVES RASH) During an interview with the Director of Patient Care Services (DPCSD) on 11/15/2024 at 12:21 p.m., the DPCS stated that she recently just got involved with the HAs and that all patients need to be re-assessed, to ensure proper criteria and care is being provided. A. During a record review of Patient 15s admission record, the admission record indicated a start of care(SOC) date of 10/11/2024, with a terminal diagnosisof Malignant neoplasm of bladder unspecified, (amedical condition that refers to bladder cancer, a typeof cancer that occurs when cells in the bladder lining mutate and multiply uncontrollably, forming tumors). During a record review of Patient 15s Current Treatment and Medication, dated 10/11/2024, indicated a list of medications including; albuterol sulfate HFA 90 micrograms/actuation inhalation aerosol (an inhaler medication which dilates the airway tubes when someone is experiencing shortness of breath) with the frequency of two puffs every four hours as needed for shortness of breath, Prednisone acetate 1% ophthalmic suspension (a steroid eye drop to help with inflammation) a frequency of one drop in each eye two times a day for eye disorder. During a concurrent interview and record review on 11/13/2024 at 11:30 am with LVN 2 at Patient 15s residence, there was no albuterol or prednisone in the patients residence. LVN 2 stated, ";its not here. The nurses that came before me should have had it discontinued if Patient 15 is not using it anymore. Nurses are supposed to check the medication on every visit." During an interview on 11/13/2024 at 11:35 am with Patient 15s daughter, Patient 15s daughter stated, ";Patient 15 has not had those two medications since June. Patient 15 doesnt use it anymore." During an interview on 11/15/2024 at 11:45 am with DPCS, DPCS stated, ";the skilled nurses are supposed to do medication reconciliation on every visit." B. During a record review of Patient 16s admission record, the admission record indicated a start of care(SOC) date of 09/05/2024, with a terminal diagnosisof acute respiratory failure with hypoxia (occurs when impairment of gas exchange between the lungs and blood causing low oxygen in the bodys tissues). During a record review of Patient 16s Current Treatment and Medication, dated 09/05/2024, indicated a list of medications including; acetaminophen 650 milligram (pain medication) frequency of one tab daily as needed indication for pain, diclofenac sodium 1% (pain gel) topical gel frequency to apply to the affected area as thin film from two times daily indication for pain, lidocaine 4% topical pain patch frequency to apply 1 patch daily to skin indication pain. During a concurrent interview and record review on 11/13/2024 at 11:45 am with LVN 2 at Patient 16s residence, there was no albuterol or prednisone in the patients residence. LVN 2 stated, ";its not here. The nurses that came before me should have had it discontinued if Patient 16 is not using it anymore. Nurses are supposed to check the medication on every visit." During an interview on 11/13/2024 at 11:50 am with Patient 16s daughter, Patient 15s daughter stated, ";Patient 16 has not had those two medications since June. Patient 15 doesnt use it anymore." During an interview on 11/15/2024 at 11:50 am with DPCS, DPCS stated, ";the skilled nurses are supposed to do medication reconciliation on every visit." During a record review of HAs policy and procedure titled, ";Medication Profile" dated 2018, the policy and procedure indicated, ";2. A drug regimen review will be performed by a registered nurse at the time of initialand comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of new medication." The policy further indicated, ";during subsequent home visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family caregiver, as well as other clinicians, understand the medication regimen." During your record review of HAs Policy and Procedure titled, ";Ongoing Assessments", dated 2018, the Policy and Procedure indicated, ";The nurse will assess each patient on each visit for: O. that compliance with treatment and medication regimen."

Based on interview and record review, the Hospice Agency (HA; an agency providing care to terminally ill patients) failed to ensure the Condition of Participation (condition that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Patient Rights was met as follows: 1. The hospice agency (HA) failed to document a reported complaint to the agency regarding requested patient's clinical records not received in their grievance ( complaint) log and its resolution (decision) for one out of 14 sampled patients (Patient 13). (Refer to L505). 2. The HA failed to ensure to inform one of 14 sampled patients (Patient 11), about the services the HA provided and the limitations of those services. (Refer to L519). The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated Federal compliance for Patients Rights to ensure Patients 11 and 13's rights were not violated and received quality hospice care. --- 1. The hospice agency (HA) failed to document a reported complaint to the agency regarding requested patient's clinical records not received in their grievance ( complaint) log and its resolution (decision) for one out of 14 sampled patients (Patient 13). (Refer to L505). 2. The HA failed to ensure to inform one of 14 sampled patients (Patient 11), about the services the HA provided and the limitations of those services. (Refer to L519). The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated Federal compliance for Patients Rights to ensure Patients 11 and 13's rights were not violated and received quality hospice care.

Based on interview and record review, the hospice agency (HA) failed to document a reported complaint, to the agency regarding a family members request for patient's clinical record, that was not received, in their grievance (complaint) log and its resolution ( decision) for one out of 14 sampled patients (Patient 13). This deficient practice placed Patient 13 and other patients at risk that grievances presented to the HHA will not be addressed and resolved. --- On 7/16/2024, at 12 p.m., a recertification survey was conducted at the HA that included a complaint regarding an allegation that FM 1 (Family member) did not receive the requested clinical records from the HA after the patient passed away on 1/9/2024. A review of Patient 13's Face Sheet (admission record), indicated the agency admitted Patient 13 on 6/20/2023, with a diagnosis that included senile degeneration of the brain (loss of intellectual ability). During a review of Patient 13's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 12/28/2023, the POC indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and three as needed visits, HHA (home health aide) twice a week for hygiene, and the SC (spiritual counseling) once a month and as needed. A review of Patient 13's Communication Log dated 2/1/2024, indicated FM 1 requested clinical records and the HA informed FM 1 to send a formal written request to send records. During an interview with the Administrator on 7/16/2024, at 1:30 p.m., The Administrator stated that she was aware of FM 1's grievance, but the agency failed to document the complaint in their grievance book with the corrective action or resolution as per their agencys policy. During a review of the agencys undated policy and procedure titled, ";Complaint/Grievance Process", the policy indicated at the time of admission, and as needed, patient/client and/or family/caregiver shall be informed of their rights to voice grievances regarding treatment or care, lack of respect of property, or recommend changes in policy, staff, or service/care without restraint, interference, coercion, discrimination, or reprisal. Grievances received from a patient/client and/or family/caregiver will be promptly reported to Office Leadership/Designee for assessment determination. Complaints and any actions taken will be documented in the complaint form. Corrective action should be specific and related to the complaint. All complaints will be logged, tracked, trended, and filed in the performance improvement office.

Based on interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure to inform one out of 14 sampled patients (Patient 11), about the services the HA provided and the limitations of those services. This deficient practice resulted in Patient 11, not being aware of the care and services the HA provided and had the potential for misinformation, misunderstanding and miscommunication of hospice care and services provided for the patients. --- During a review of Patient 11s admission record indicated a start of care (SOC) date of 4/25/2024, with a terminal diagnosis of end stage heart failure (a specific type of heart failure that occurs in the heart's left ventricle). During a review of Patient 11's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 7/11/2024, the POC indicated an order for the SN (skilled nurse) to provide skilled nursing visits once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). During a telephone interview on 7/17/2024, at 2 p.m., with Patient 11's FM1 (Family Member), FM1 stated that she did not have an idea what hospice services were about. FM 1 stated the HA would send a nurse (unidentified) to come visit her every week to take her vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and would provide wound treatment. FM 1 also stated Patient 11 was not sick and that she was not dying in the next six months. During an interview with the Director of Patient Care Services (DPCSD) on 7/25/2024 at 12:21 p.m., the DPCS stated the admission process starts when they receive referrals from patients friends, or community referrals. The DPCS also stated the HA will send a visiting nurse and would explain to the patient and to the patients family the kind of service they provide and the limitations of these services. During a review of the agencys undated policy and procedure titled, ";Rights/Responsib, indicated each patient will be an active, informed participant in his/her plan of care. The patient will be informed during the initial assessment visit, in advance of furnishing care, of the hospice philosophy and program of care, the organizations mission and care and services provided directly or through contractual arrangements, and the goals of hospice, the interventions that support those goals and the identification of the staff providing service. A review of the agency's undated policy " Admission Information" indicated the agency is to provide patients with accurate information to make informed decisions regarding care or services. The scope of services included: Nursing Hospice aide and homemaker services Physical therapy Occupational therapy Speech language pathology Social Worker Physician services Volunteers Counselors Dietary counseling Home medical equipment related to terminal illness Drugs and biologicals related to terminal illness Short term inpatient care Respite care Continuous care Bereavement counseling and medical supplies At time of initial assessment, Hospice will provide each patient with a statement of the scope of services provided directly and/or through contractual/written agreement. Patients will also be provided the following information: Care/service limitations Eligibility criteria Charges or patient liability for care/services Information regarding the Medicare Hospice benefit

Based on interview and record review, the hospice agency (HA; agency providing care to terminally ill patients) failed to ensure the Condition of Participation (condition that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Initial and Comprehensive Assessment of the patient was met as follows: 1. The HA failed to conduct an initial comprehensive assessment (an evaluation of the patient's physical, psychosocial [mental, social, and spiritual aspects], and emotional status related to the terminal illness [illness with a prognosis of having six months of life or less to live]) within 48 hours of the admission date of 7/10/2024, in order to develop and implement an individualized plan of care to address the physical, emotional, and spiritual needs for one of fourteen sampled patients (Patient 2). (Refer to L522). 2. The Director of Patient Care Services (DPCS) did not oversee the completion of initial comprehensive assessment of patients within 48 hours of admission for one of fourteen sampled patients (Patient 2). (Refer to L522). 3. The HA failed to conduct an initial bereavement assessment for two of fourteen sampled patients (Patient 1 and Patient 2). (Refer to L531). 4. The HA failed to take into considerations the complications and risk factors that affect care planning for one of fourteen sampled patients (Patient 1). (Refer to L526). 5. The HA failed to conduct and document a comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for three of fourteen sampled patients (Patient 1, Patient 11,and Patient 12). (Refer to L524). This deficient practice had the potential to cause a delay in patient care, uncontrolled patient pain, and undetected signs of physical, emotional, and spiritual needs when transitioning to final stages during the dying process. The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated (State Law) compliance with Federal Regulations for Initial and Comprehensive Assessment of Patient to ensure the highest quality health care is provided to patients assessed to receive hospice services. --- .

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to assess one of fourteen sampled patients (Patient 2) for hospice care and services by failing to: 1. Conduct an initial comprehensive assessment (an evaluation of the patient's physical, psychosocial [mental, social, and spiritual aspects], and emotional status related to the terminal illness [illness with a prognosis of having six months of life or less to live]) within 48 hours of admission in order to develop and implement an individualized plan of care to address the physical, emotional, and spiritual needs for Patient 2. 2. The Director of Patient Care Services (DPCS) did not oversee the completion of initial comprehensive assessment of patients within 48 hours of admission. This deficient practice had resulted in Patient 2 not being monitored for signs and/or symptoms of hypotension (low blood pressure) or hypertension (high blood pressure) crisis that could lead to serious harm. This deficient practice also resulted in the HA providing care without assessing and identifying the needs of the patient that can potentially affect the patients care and services. --- A review of Patient 2s ";Personal Information" indicated a start of care (SOC) date of 7/10/2024, with a primary diagnosis of end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest; symptoms may include shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 7/16/2024, at 2:50 p.m., the DPCS reviewed Patient 2s ";Comprehensive Nursing Assessment," dated 7/10/2024. The DPCS confirmed the Comprehensive Nursing Assessment was blank. The DPCS stated if it was not documented, then it was not done. The DPCS stated that patients need to have a comprehensive assessment within forty eight hours after the hospice referral. When asked about the negative outcome of not completing the initial comprehensive assessment within 48 hours, the DPCS stated that the patient might have a change of condition at any time, and the HA would not be able to address the needs if patient was not assessed timely. According to the DPCS, after the completion of the comprehensive assessment by a Registered Nurse, an initial Plan of Care (POC; a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver) would be initiated to meet the patients needs, which made completing the comprehensive assessment within 48 hours very important. During a joint home visit to Patient 2s residence on 7/17/2024 at 11:10 a.m. with the DPCS, Patient 2 was observed sitting in a chair, awake, alert, and oriented. On 7/17/2024, at 12:10 p.m., during an interview with Family Member 2 (FM 2), who acted as Patient 2s primary caregiver, FM 2 stated that after Patient 2 was staying at a Skilled Nursing Facility (SNF, a facility that provides 24 hour skilled nursing care, as well as rehabilitative services; the typical resident is a person who is chronically ill or recuperating from an illness or surgery and needs regular nursing care and other health related services) due to a fall. FM 2 stated that Patient 2 was going to be discharged from the SNF and she felt overwhelmed in managing Patient 2s health care needs at home. FM 2 stated that Patient 2 had a lot of medications and doctor appointments, and she did not have anybody to help her care for Patient 2. A medication review with the DPCS was conducted during the home visit, at 1:35 p.m. During the medication review, the survey team observed that Patient 2 was on the following medications: - Multivitamin centrum 1 tablet daily. - Iron (a supplement) 65 mg 1 tablet daily. - Vitamin D3 (a supplement) 50 mcg 2000 IU 1 tablet daily. - Pantoprazole 40 mg tablet, 1 tablet by mouth before breakfast. - Unknown pill in pill box, according to FM 2 it was a medication for acid reflux (a digestive disease in which stomach acid or bile irritates the stomach lining), per FM 2 Patient 2 takes 1 tablet by mouth 30 minutes before breakfast. - Eliquis (a prescription medicine used to reduce the risk of stroke and blood clots) 5 mg tablet, take ½ tablet by mouth twice daily. - Aspirin (a medication used to treat pain and reduce fever or inflammation; it is sometimes used to treat or prevent heart attacks, strokes, and chest pain) 81 mg EC, take 1 tablet once a day. - Furosemide (a medication to treat fluid retention [edema], can also treat high blood pressure) 40 mg tablet, take ½ tablet in AM and ½ tablet in PM. - Losartan (a medication to treat high blood pressure) 100 mg tablet, take ½ tablet by mouth daily. - Metoprolol tartrate (a medication to treat high blood pressure) 25 mg tablet, take ½ tablet by mouth twice daily. During an interview with the DPCS on 7/24/2024, at 1:41 p.m., the DPCS stated Patient 2 could experience side effects such as bleeding from taking Aspirin. Per DPCS, Patient 2 was no longer taking Eliquis. The DPCS also stated that Losartan and Metoprolol could make the patient dizzy, which would increase her risk for falls. A review of the HAs policy, titled ";Comprehensive Assessment," dated 2018, indicated that a comprehensive patient assessment will be performed by the interdisciplinary group no later than five calendar days after the election of hospice care in consultation with the attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least the following information: E. Current treatment and patient response to that treatment. A review of the HAs job description summary for Director of Patient Care Services (DPCS) indicated the DPCS coordinates and oversees all direct and indirect patient services provided by clinical organization personnel.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to conduct and document a comprehensive assessment that reflected the patient's current health status and identify the patients' needs for hospice care and services related to hospice eligibility and management of terminal illness for three of fourteen sampled patients (Patient 1, Patient 11, and Patient 12). This deficient practice had the potential for Patient 1, Patient 11, and Patient 12 not to receive care and services. --- A review of Patient 12's clinical record indicated Patient 12 was admitted to the hospice agency on 6/17/2024, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). The clinical record further indicated the ";referring/attending/patient choice" physician was blank with no signature for the referring physician. A review of Patient 12s Physicians Certification for Hospice Benefit dated 6/17/2024 to 9/14/2024, Benefit Period #1, indicated Physician 1 signed the attending physician referral section to indicate Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 12s General Acute Care Hospital (GACH) dated 6/15/2024, indicated Patient 12 was admitted due to weakness, and urinary tract infection, and that Patient 12 was alert and oriented, and stated age with no acute distress. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 7/24/2024, at 11 a.m., during a phone interview with Patient 12s Patient Caregiver (PCG) 1, he stated he was aware that Patient 12 was not hospice, and that Patient 12 did not have a diagnosis of Alzheimers disease. Family Member 1 stated that Patient 12 sees her primary doctor at least twice since she has been on hospice and Patient 12 had a doctors appointment with her primary physician on 7/25//2024, at 3:30 p.m. PCG 1 stated he knows what hospice is, however, a staff at the hospital has put her on hospice, even though they knew she was not dying. Family member 1 stated that a nurse will come to visit Patient 12 every week to check her, and another one will come to bathe her. During a concurrent record review and interview of Patient 12's electronic record with the Director of Patient Care Services in the HA's office on 7/24/2024, during a telephone interview with Patient 12s primary physicians office staff, she stated that they were not aware Patient 12 was on hospice. The hospice or the patient never informed them. The office staff stated if they knew Patient 12 was on hospice they would have never seen her since that is double billing. The PCPs office staff stated Patient 12 does not have Alzheimer's and that she does not have six months or less to live. During a phone interview on 7/24/2024 at 12:20 p.m., with the Medical Director (MD), when asked what criteria the MD uses to certify patients for hospice. The MD stated, ";Information I receive from the nurses, I look at notes, talk to staff and go by the LCD criteria. I look over what is scanned for history and physical and I go based on the nurses narrative because they see the patient." When asked if the primary care physician of the patient is contacted, the MD stated, ";Sometimes if they already have the order than thats what I go by most of the time its from the hospital and its the hospital records." When asked if MD reviews any clinical documents for the patients before certifying for hospice, the MD stated, ";Any records I have, hospital records, last note, what the nurse saw." During a review of Patient 11s admission record indicated a start of care (SOC) date of 4/25/2024, with a terminal diagnosis of end stage heart failure (a specific type of heart failure that occurs in the heart's left ventricle). During a review of Patient 11s Comprehensive Nursing Assessment, dated 4/26/2024, indicated Patient 11 required a cane and stand by assist to ambulate, has regular heart pulse. There is no edema (fluid buildup in the extremities) or shortness of breath indicated. Clear lung sounds, no cough and 99% Oxygen Saturation (amount of oxygen in the blood) on room air. During a review of Patient 11s ";LCD Hospice Eligibility Determination" (local coverage determination for Hospice eligibility used by national government services used to determine guidelines for terminally ill patients and if they have a life expectancy of six months or less), dated 4/26/2024, indicated for NYHA classification under A. Does this CHF (congestive heart failure, the heart's capacity to pump blood cannot keep up with the body's need the term congestive refers to the resulting buildup of fluids in the ankles and feet, arms, lungs, and or other organs), or angina patient meet the criteria for NYHA Class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort) level? Yes." The LCD guidelines also indicated patient has declined surgical procedure for the terminal diagnosis. During a phone interview on 7/23/2024 at 11:15 pm Patient 11s daughter, Patient 11s daughter stated, ";my father does not have any heart failure. The only heart related issue he has is high blood pressure. My dad can walk without having any shortness of breath on flat areas, if he has to go up a flight of stairs he might get a little short of breath because hes older. He can walk about a block with no assistance and no shortness of breath. He doesnt use any oxygen either." During a review of Patient 11s clinical record Progress Note from Medical Clinic, dated 4/3/2024, the Progress note indicated, ";Medical History: Type 2 Diabetes (a condition which results in poor circulation of blood sugar), Hypertension (high blood pressure), Hyperlipidemia ( high cholesterol levels in the blood), Acid Reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining), left toe amputation 3/2024." During a phone interview on 7/24/2024 at m 12:25 pm, with Medical Director (MD), when asked what criteria MD uses to certifies patients for hospice, MD stated, ";information I receive from the nurses, I look at notes, talk to staff and go by LCD criteria. I look over what is scanned for history and physical and I go based on the nurses narrative because they see the patient." When asked if the primary care physician of the patient is contacted, MD stated, ";Sometimes if they already have the order than thats what I go by most of the time its from the hospital and its the hospital records." When asked if MD reviews any clinical documents for the patients before certifying for hospice, MD stated, ";any records I have, hospital records, last note, what the nurse saw." When asked what information is needed to diagnose a patient with end stage heart failure, MD stated." The notes and records, actual documented type of heart disease. Also lab tests, like BNP (Brain natriuretic peptide, blood test that measures the levels of a protein hormone in your bloodstream which is produced by the heart and blood vessels and higher levels and indicate heart inability to pump blood throughout the body or heart failure), blood pressure, edema, shortness of breath by just sitting there, echo (echocardiogram, ultrasound scan which uses sound waves to create pictures of the heart. This common test can show blood flow through the heart and the heart valves, which is used to find heart disease and other heart conditions), any history heart disease documents." When asked what criteria is used to determine NYHA class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort), MD stated, ";not able to carry any physical activity without discomfort, they will have, edema and cough varies but will have shortness of breath." When asked for Patient 11, what criteria was used to determine end stage heart failure and NYHA 4, MD stated, ";I went by the diagnosis the nurse listed in the CTI (certification of terminal illness) and talk to the nurse about Patient 11s symptoms. I usually do it based on what is verbally reported to me by the nurse and and times look at the notes. Doesnt look like Patient 11 qualifies for hospice based on the history and physical in the chart. I dont know where the nurse got the information from. Based on what I am looking at now this patient doesnt qualify for hospice. I am not sure if I had looked at history and physical before. I just took the nurses assessment. You have to interview the nurse. They put in the diagnosis in the system. They tell me hey this patient has End stage heart failure and they put it in the system. I just do the physician narrative. The nurses put the diagnosis and everything else in the system." During a concurrent interview and record review on 7/24/2024 at 2:20 pm with DPCS of Patient 11s comprehensive Nursing Assessment, DPCS stated, ";based on the review of the nurses assessment, the physical assessment does not match with the LCD guidelines. It says here Patient 11 didnt have any edema, shortness of breath, no oxygenation issues, but the LCD guidelines has the NYHA Class 4 parked as yes which means the patient should have displayed shortness of breath on minimal exertion, and edema." During a record review of the HAs policy and procedure titled, ";Comprehensive Assessment", dated 2018, the policy and procedure indicated, ";the assessment should determine: A. Probable prognosis of 6 months or less B. Patient problems and needs related to the terminal illness C. Patient goals related to terminal illness D. Type of service, frequency, and duration needed to meet patient care needs..." the policy further indicated, ";4. The Clinical Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis." During a record review of the HAs policy and procedure titled, ";Clinical/Service Data Collection", dated, 2018, the policy and procedure indicated, ";Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care of services provided." a. A review of Patient 1s ";Personal Information" indicated a start of care (SOC) date of 7/7/2024, with a primary diagnosis of acute (severe and sudden in onset) diastolic congestive heart failure (a condition in which the hearts main pumping chamber [left ventricle] becomes stiff and unable to fill properly). A review of Patient 1s ";Comprehensive Nursing Assessment," dated 7/7/2024, indicated that Patient 1s past medical history included end-stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids) on hemodialysis (a life-saving treatment for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure). However, the ";Current Issues and Findings" section did not mention hemodialysis. The ";Comprehensive Nursing Assessment" did not address that Patient 1 was still undergoing hemodialysis (HD), the frequency of HD, or the HD access. The narrative section of the Comprehensive Nursing Assessment did not mention what the HA staff needed to monitor, or what Patient 1 and/or the family or caregiver needed to monitor and report to the HA. During a telephone interview with Patient 1 on 7/17/2024, at 10;10 a.m., Patient 1 stated that he had been on dialysis for six years. Patient 1 stated he had a fistula (a connection that was made between an artery [a blood vessel that carries blood from the heart to tissues and organs in the body] and a vein [a blood vessel that collects oxygen-poor blood and return it to the heart] for dialysis access on his left upper arm. Patient 1 stated he went on dialysis three times a week. A review of Patient 1s ";History of Nursing Assessment" indicated that Patient 1 only had one nursing assessment, which was the Comprehensive Nursing Assessment on 7/7/2024. During an interview with the Director of Patient Care Services (DPCS) on 7/24/2024, at 1:53 p.m., the DPCS stated that she was aware that Patient 1 was on hemodialysis three times a week. The DPCS stated the comprehensive nursing assessment should have included the hemodialysis treatment for Patient 1, including the frequency and type of dialysis access. According to the DPCS, it was important to include the dialysis treatment in the comprehensive assessment, because it is what the plan of care will be based on. A review of the HAs policy, titled ";Comprehensive Assessment," dated 2018, indicated that during the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least the following information: K. Patients past and present medical and psychosocial history including pertinent diagnosis and any co-morbid conditions.

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 take into considerations the complications and risk factors that affect care planning for one of fourteen sampled patients (Patient 1). This deficient practice had the potential to result in complications and risk factors not being monitored for Patient 1. --- A review of Patient 1s ";Personal Information" indicated a start of care (SOC) date of 7/7/2024, with a primary diagnosis of acute (severe and sudden in onset) diastolic congestive heart failure (a condition in which the hearts main pumping chamber [left ventricle] becomes stiff and unable to fill properly). A review of Patient 1s ";Comprehensive Nursing Assessment," dated 7/7/2024, indicated Patient 1s past medical history included end-stage renal disease (a condition in which the kidneys lose the ability to remove waste and balance fluids) on hemodialysis (a life-saving treatment for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure). However, the ";Current Issues and Findings" section did not mention hemodialysis. The ";Comprehensive Nursing Assessment" did not address that Patient 1 was still undergoing hemodialysis (HD), the frequency of HD, or the HD access. The narrative section of the Comprehensive Nursing Assessment did not mention what the HA staff needed to monitor, or what Patient 1 and/or the family or caregiver needed to monitor and report to the HA. A review of Patient 1s ";History of Nursing Assessment" indicated that Patient 1 only had one nursing assessment, which was the Comprehensive Nursing Assessment on 7/7/2024. During a telephone interview with Patient 1 on 7/17/2024, at 10;10 a.m., Patient 1 stated that he had been on dialysis for six years. Patient 1 stated he had a fistula (a connection that was made between an artery [a blood vessel that carries blood from the heart to tissues and organs in the body] and a vein [a blood vessel that collects oxygen-poor blood and return it to the heart] for dialysis access on his left upper arm. Patient 1 stated he went to dialysis three times a week. During an interview with the Director of Patient Care Services (DPCS) on 7/24/2024, at 1:53 p.m., the DPCS stated that she was aware that Patient 1 was on hemodialysis three times a week. The DPCS stated the comprehensive nursing assessment should have included the hemodialysis treatment for Patient 1, including the frequency and type of dialysis access. According to the DPCS, it was important to include the dialysis treatment in the comprehensive assessment, because it is what the plan of care will be based on. A review of the HAs policy, titled ";Comprehensive Assessment," dated 2018, indicated that during the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least the following information: J. Complications and risk factors that affect care planning.

Based on interview and record review, the Hospice Agency (HA; agency providing care to terminally ill patients who have six months or less to live) failed to conduct an initial bereavement assessment for two of fourteen sampled patients (Patient 1 and Patient 2). This deficient practice had the potential to result in the patient/family not being provided social, spiritual, and cultural support related to the patients anticipated death. --- a. A review of Patient 1s ";Personal Information" indicated a start of care (SOC) date of 7/7/2024, with a primary diagnosis of acute (severe and sudden in onset) diastolic congestive heart failure (a condition in which the hearts main pumping chamber [left ventricle] becomes stiff and unable to fill properly). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 7/16/2024, at 3:10 p.m., the DPCS reviewed ";History of Bereavement Assessment" for Patient 1, which was blank. The DPCS confirmed there was no bereavement assessment completed for Patient 1 since admission. b. A review of Patient 2s ";Personal Information" indicated a start of care (SOC) date of 7/10/2024, with a primary diagnosis of end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest; symptoms may include shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 7/16/2024, at 2:50 p.m., the DPCS reviewed ";History of Bereavement Assessment" for Patient 2, which was blank. The DPCS confirmed there was no bereavement assessment completed for Patient 2 since admission. During an interview with the DPCS on 7/16/2024 at 3:35 p.m., the DPCS stated that the initial bereavement assessment needed to be completed within five days after admission. The DPCS stated that without an initial bereavement assessment, the HA would not be able to assess patients and/or familys concerns regarding death, patients support system, and how the HA could provide support for the patient and family. A review of the HAs policy, titled ";Bereavement Assessment," dated 2018, indicated that on admission, the social worker, chaplain, or hospice registered nurse will complete a bereavement assessment that is given to the Bereavement Coordinator. At a minimum, it will include: A. Patient and family/caregiver loss issues. B. Survivor needs. C. Social, spiritual, and cultural factors. D. Services to be provided including individual counseling, support groups, and letters and cards. E. Referrals to be made. F. Grief risk factors and potential for pathological grief reactions.

Based on interview and record review, the hospice agency (HA; agency providing care to terminally ill patients) failed to ensure the Condition of Participation (condition that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for IDG, CARE PLANNING, COORDINATION OF SERVICES was met as follows: --- 3. The HA failed to ensure that an individualized Plan of Care (POC; a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver) was developed for two of fourteen sampled patients (Patient 1 and Patient 2) based on identified initial and updated assessments to address the management of health status of the patients. (Refer to L545). 4. The HA failed to ensure IDG meetings were signed by the physician, registered nurse, social worker (MSW), and Chaplain for four of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4). (Refer to L554) The hospice agency failed to ensure home visit was conducted in accordance with the plan of care (POC) for one of 14 sampled patients (Patient 13).(Refer to L543). The director of patient care services (DPCS) failed to coordinate care by ensuring a prescribed breathing treatment was administered and a visiting nurse was sent for evaluation to a patient having a change of condition for one out of 14 sampled patients (Patient 13). (Refer to L556). The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated Federal compliance for IDG, CARE PLANNING, COORDINATION OF SERVICES, to ensure Patients 13 receive the quality of hospice care.

Based on interview and record review, the hospice agency failed to ensure a home visit was conducted in accordance with the plan of care (POC) for one of 14 sampled patients (Patient 13). This failure had the potential to negatively affect the patients' physical comfort, psychosocial well-being, and risk of not receiving the needed and necessary services timely. --- On 7/16/2024, at 12 p.m., a recertification survey was conducted at the hospice agency (HA) that included a complaint regarding an allegation that the prescribed breathing treatment was not administered to treat Patient 13's shortness of breath and there was no nurse visit conducted to assess Patient 13, who was having a change of condition (COC). On 1/9/2023, Patient caregiver (PCG 1) notified the HA that Patient 13 died. A review of Patient 13's Face Sheet (admission record), the Face Sheet indicated the agency admitted Patient 13 on 6/20/2023, with a diagnosis that included senile degeneration of the brain (loss of intellectual ability). During a review of Patient 13's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 12/28/2023, the POC indicated an order for the SN (skilled nurse) to provide skilled nursing visits of once a week and three as needed visits, HHA (home health aide) for twice a week for hygiene, and SC (spiritual counseling) for once a month and as needed. A review of Patient 13's Plan Of Care summary indicated the following medication/treatment orders: a. 1/7/2024- to provide Nebulizer Mask and Mini Compressor. b. 6/21/23- to administer Ipratropium Bromide/Albuterol Sulfate -0.5 mg (milligrams)- 3 mg/ 3 ml(milliliters) solution for inhalation every six hours as needed for shortness of breath and congestion. A review of Patient 13's Communication Log dated 1/7/2024, indicated the HA received a phone call from Medication Technician (MT 1) from the boarding care facility reporting Patient 13 was potentially having COVID (a disease caused by a virus), the HA instructed MT 1 to administer breathing treatment and the HA will dispatch a nurse and will make a visit by tomorrow. During an interview with the DPCS on 1/16/2024, at 2:45 p.m., the DPCS stated that she received a phone call from MT 1 reporting Patient 13 had COVID, with symptoms of fever and slight shortness of breath. The DPCS also stated MT 1 told her that she won't be able to administer the Albuterol breathing treatment because the patient had no physician's order for the Nebulizer mask/mini-compressor and the facility could not find the patient's nebulizer. The DPCS also stated she told MT 1 that she will order the nebulizer and have it delivered to the facility and a nurse will be sent the next day to evaluate patient's condition. When DPCS was asked if she had followed up with the Nebulizer order and if the nurse visit was done, she stated "No." The DPCS further stated they could not find any documentation that there was a nurse visit done on 1/7/2024 and 1/8/2023. A review of Patient 13's Visit Notes indicated Patient 13 had a visit on 1/3/2024 and 1/9/2024. During an interview with MT 1 on 7/16/2024, at 11 a.m., MT 1 stated there was no nurse visit by the HA on 1/7 and 1/8/2024. During a review of the agency's undated policy and procedure titled, "The Plan of Care", indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will include all services necessary for the palliation and management of the terminal illness and related conditions.

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 an individualized Plan of Care (POC; a document that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver) was developed for two of fourteen sampled patients (Patient 1 and Patient 2) based on identified initial and updated assessments to address the management of health status of the patients. This deficient practice had the potential to result in Patient 1 and Patient 2 not receiving the services that meet their needs and not receiving the appropriate interventions that address their concerns related to the terminal illnesses. --- a. A review of Patient 1s ";Personal Information" indicated a start of care (SOC) date of 7/7/2024, with a primary diagnosis of acute (severe and sudden in onset) diastolic congestive heart failure (a condition in which the hearts main pumping chamber [left ventricle] becomes stiff and unable to fill properly). During a telephone interview with Patient 1 on 7/17/2024, at 10:10 a.m., Patient 1 stated that he had been on dialysis (a life-saving treatment for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure) for six years. Patient 1 stated he had a fistula (a connection that was made between an artery [a blood vessel that carries blood from the heart to tissues and organs in the body] and a vein [a blood vessel that collects oxygen-poor blood and return it to the heart] for dialysis access on his left upper arm. Patient 1 stated he went on dialysis three times a week. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 7/16/2024, at 3:10 p.m., the DPCS reviewed Patient 1s ";POC/IDG Review," (Plan of Care/Interdisciplinary Group Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) dated 7/11/2024 and ";Plan of Care," dated 7/16/2024. The DPCS confirmed the ";IDG Discussion" and ";Plan of care" sections for Patient 1 were blank. The DPCS also confirmed that the POC/IDG review was not signed by IDG members, except for the Medical Director (MD). The DPCS stated that as of 7/16/2024, Patient 1 did not have any interventions and goals established. b. A review of Patient 2s ";Personal Information" indicated a start of care (SOC) date of 7/10/2024, with a primary diagnosis of end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest; symptoms may include shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]). During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 7/16/2024, at 2:50 p.m., the DPCS reviewed Patient 2s ";POC/IDG Review," dated 7/11/2024, and ";Plan of Care," dated 7/16/2024. The DPCS confirmed the ";IDG Discussion" and ";Plan of care" sections for Patient 2 were blank. The DPCS also confirmed that the POC/IDG review was not signed by IDG members, except for the Medical Director (MD). The DPCS stated that as of 7/16/2024, Patient 2 did not have any interventions and goals established. During a joint home visit to Patient 2s residence on 7/17/2024 at 11:10 a.m. with the DPCS, a medication review was completed. During the medication review, it was noted that Patient 2 was on blood pressure medications such as Losartan and Metoprolol, and Aspirin, which is an antiplatelet (a medication that interferes with the process of platelets binding together). During an interview with the DPCS on 7/16/2024 at 3:35 p.m., the DPCS stated the purpose of a care plan was to assess a patients needs and describe the interventions needed to meet the needs. When asked how the staff would provide the care for Patient 1 and Patient 2 since they did not have a care plan, the DPCS stated the HA staff utilized a group chat that discussed each staffs task for the day, such as bringing patient supplies or ordering medication refills. The DPCS stated the group chat was not part of a patients chart and did not replace a plan of care. When asked how the HA would monitor if the goals had been achieved or if the interventions were effective without a care plan, the DPCS stated the HA would not be able to monitor. According to the DPCS, the HA was supposed to formulate the initial plan of care within five days after the start of care. During an interview with the DPCS on 7/24/2024 at 1:53 p.m., the DPCS stated that Patient 1 was on dialysis, which made it very important to monitor things such as infection and bleeding on the dialysis access. The DPCS stated for Patient 2, She needed to be monitored for adverse effects related to the medications she was taking. The DPCS restated the importance of plan of care being generated timely. A review of the HAs policy, titled ";Interdisciplinary Group Plan of Care," revised November 2020, indicated that the type and scope of services provided by the interdisciplinary group will be based upon comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The HAs policy did not cover the content of a plan of care.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure IDG meetings were signed by the physician, registered nurse, social worker (MSW), and Chaplain for four of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4) The deficient practice had the potential to result in a lack of directing, coordinating, and supervising of the care and services provided by the interdisciplinary group. --- a. A review of Patient 5's clinical record indicated Patient 5 was admitted to the hospice agency on 1/16/2024, with a terminal diagnosis of Heart disease unspecified (a group of disorders that affect the heart and blood vessels). A review of Patient 5's POC/IDG Review forms dated 6/27/2024, 7/11/2024, and 1/16/2024, did not have the MD, Chaplains signature and the MSW was signed by the Administrator , who did not meet the qualifications. b. A review of Patient 7's clinical record indicated Patient 7 was admitted to the hospice agency on 10/26/2023, with a terminal diagnosis of Heart disease unspecified(a group of disorders that affect the heart and blood vessels). A review of Patient 7s POC/IDG Review forms dated 2/8/2024, did not have the Medical Director and the Master of Social works (MSW) signature. A review of Patient 7's POC/IDG/Review form dated 1/11/2024, had the administrators signature as the MSW. A review of Patient 7's POC/IDG Review form dated 1/25/2024, did not have the MD's and MSW's Signatures. c. A review of Patient 12's clinical record indicated Patient 12 was admitted to the hospice agency on 6/17/2024, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 12s initial POC/IDG Review forms dated 6/17/2024, was not signed by the MD and was signed by the MSW who does not meet qualifications. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During an interview with the administrator on 7/22/2024 at 3p.m. and 7/24/2024, at 2p.m, she stated she has a Bachelor's degree in Social work and she was signing as the Medical Social Worker. A review of the ADM employee file indicated she had a certificate of a degree in bachelor in Arts in Psychology (the scientific study of mind and behavior). There was no documentation that she meat the qualifications to be the Social worker. A review of the Hospice Agency's (HA) form titled, "Job Title/Position: Social Worker/Social Worker Associate/Associate Social Worker " under Essential Job Functions/Responsibilities -12. indicates, "Unlicensed social worker shall inform each patient or client prior to performing any such functions that he or she is not licensed clinical social worker, marriage and family therapist, licensed professional clinical counselor, or licensed psychologist or a licensed psychiatrist, whichever is applicable. Business and Professional Code Section 4990.20 and 4996.15." A continued review of the form under Position Qualifications-1. stipulates, " Graduate of the Master's or doctoral program in social work accredited by the Council on Social Education. Meet California requirements Section 1870 of California Code of Regulations." a. A review of Patient 1s ";Personal Information" indicated a start of care (SOC) date of 7/7/2024, with a primary diagnosis of acute (severe and sudden in onset) diastolic congestive heart failure (a condition in which the hearts main pumping chamber [left ventricle] becomes stiff and unable to fill properly). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 7/16/2024 at 3:10 p.m., the DPCS reviewed Patient 1s ";Plan of Care/Interdisciplinary Group Review" (POC/IDG Review; a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors), dated 7/11/2024. The DPCS verified the POC/IDG Review was missing the RN, MSW, and Chaplain signatures. There was no documented evidence of coordination of care between the IDG members. b. A review of Patient 2s ";Personal Information" indicated a start of care (SOC) date of 7/10/2024, with a primary diagnosis of end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest; symptoms may include shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]). During a concurrent record review and interview with the DPCS on 7/16/2024 at 2:50 p.m., the DPCS reviewed Patient 2s ";POC/IDG Review," dated 7/11/2024. The DPCS verified the POC/IDG Review was missing the RN, MSW, and Chaplain signatures. There was no documented evidence of coordination of care between the IDG members. c. A review of Patient 3s ";Personal Information" indicated a start of care (SOC) date of 5/5/2024, with a primary diagnosis of end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest; symptoms may include shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]). A review of Patient 3s ";POC/IDG Review," dated 7/11/2024, 6/27/2024, and 6/14/2024, indicated all POC/IDG Reviews were missing the MD, RN, and Chaplain signatures. There was no documented evidence of coordination of care between the IDG members. A review of Patient 3s ";POC/IDG Review," dated 5/30/2024 and 5/16/2024 indicated both POC/IDG Reviews were missing the MD signature, and the 5/16/2024 POC/IDG Review was also missing the RN signature. d. A review of Patient 4s ";Personal Information" indicated a start of care (SOC) date of 7/10/2024, with a primary diagnosis of acute (severe and sudden in onset) and chronic (persistent for a long time or constantly recurring) respiratory failure (a condition that develops when the lungs cannot get enough oxygen into the blood) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). A review of Patient 4s ";POC/IDG Review," dated 7/11/2024, indicated that it was missing the MD, RN, and Chaplain signatures. There was no documented evidence of coordination of care between the IDG members. A review of the HAs policy, titled ";Interdisciplinary Group Plan of Care," revised November 2020, indicated that written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patients clinical record, and will involve the hospice patients attending physician.

Based on interview and record review, the Director of Patient Care Services (DPCS) failed to coordinate care by ensuring a prescribed breathing treatment was administered and a visiting nurse was sent for evaluation to one out of 14 sampled patients (Patient 13) who had a change of condition. This failure had the potential to result in a delay of care, symptom management, and undetected signs of physical, emotional, spiritual needs when transitioning to the final stages of the dying process. --- On 7/16/2024, at 12 p.m., a recertification survey was conducted at the hospice agency (HA) that included a complaint regarding an allegation that the prescribed breathing treatment was not administered to treat Patient 13's shortness of breath and that there was no nurse visit to assess Patient 13, who was having a change of condition (COC). On 1/9/2024, patient caregiver (PCG 1) notified the HA that Patient 13 died. A review of Patient 13's Face Sheet (admission record), the Face Sheet indicated the agency admitted Patient 13 on 6/20/2023, with a diagnosis that included senile degeneration of the brain (loss of intellectual ability). During a review of Patient 13's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 12/28/2023, the POC indicated an order for SN (skilled nurse) to provide skilled nursing visits of once a week and three as needed visits, HHA (home health aide) for twice a week for hygiene, and SC (spiritual counseling) for once a month and as needed. A review of Patient 13's Plan Of Care summary indicated the following medication/treatment orders: a. 1/7/2024- to provide Nebulizer Mask and Mini Compressor. b. 6/21/23- to administer Ipratropium Bromide/Albuterol Sulfate -0.5 mg (milligrams)- 3 mg/ 3 ml(milliliters) solution for inhalation every six hours as needed for shortness of breath and congestion. A review of Patient 13's Communication Log dated 1/7/2024, indicated the HA received a phone call from medication technician (MT 1) from the boarding care facility reporting Patient 13 was potentially having COVID ( a disease caused by a virus), the HA instructed MT 1 to administer breathing treatment and the HA will dispatched a nurse and will make a visit by tomorrow. During an interview with the DPCS on 1/16/2024, at 2:45 p.m., the DPCS stated that she received a phone call from MT 1 reporting Patient 13 had COVID with symptoms of a fever and slight shortness of breath. DPCS also stated MT 1 told her that she won't be able to administer the Albuterol breathing treatment because the patient had no physician's order for the Nebulizer mask/mini-compressor and the facility could not find the patient's nebulizer. DPCS also stated she told MT 1 that she will order the nebulizer and have it delivered to the facility and a nurse will be sent the next day to evaluate Patient 13"s condition. When DPCS was asked if she had followed up with the Nebulizer order and if the nurse visit was done, she stated "No." The DPCS further stated they could not find any documentation that there was a nurse visit done on 1/7/2024 and 1/8/2023. A review of Patient 13's Visit Notes indicated Patient 13 had a visit on 1/3/2024 and 1/9/2024. During an interview with MT 1 on 7/16/2024, at 11 a.m., MT 1 stated there was no nurse visit by the HA on 1/7/2024 and 1/8/2024. MT 1 also stated the DPCS was aware that the facility needed an order for the nebulizer. MT 1 further stated the patient's breathing treatment was not administered because the HA did not fax the physician's order for the Nebulizer at all. During an interview with the Administrator, She stated the HA does not fax or email physician's order for any DME supplies such as Nebulizer mask and mini compressor to a boarding care facility. During a review of the agencys undated policy and procedure" Coordination of Care with Contract Agreement", indicated the hospice program will retain responsibility for evaluating services, maintaining professional management responsibility, and ensuring continuity of care in all settings through its performance improvement program or corporate compliance program. During a review of the agencys undated policy and procedure titled, ";Interdisciplinary Group Plan of Care", indicated the hospice interdisciplinary group will retain professional management responsibilities for the provision of services, including inpatient care, and will ensure that services are furnished in a safe and effective manner. Written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patients clinical record and will involve the hospice patients attending physician.

Based on interview and record review, the hospice agency failed to ensure the Conditions of Participation for Organization and Administration of Services were met as follows: 1. The hospice agency failed to ensure that the Administrator was knowledgeable regarding hospice regulations and that the governing body or administrator assumed full legal responsibility for the management, provision of all hospice services, continuous quality assessments and performance improvement, and appointed a qualified administrator to run the day to day operations of the hospice ( Refer to L0651) --- .

Based on record review and interview, the hospice agency failed to ensure the governing body assumed full legal responsibility for the management ,the provision of all hospice services, continuous quality assessment and performance improvement, and appointed a qualified administrator to run the day to day operation of the hospice. --- On 7/22/2024, at 2:30 p.m. a review of the ADM. employee file indicated she had a certificate of a degree in bachelor in Arts in Psychology (the scientific study of mind and behavior), issued on 11/13/2014. There was no documentation that she met the qualifications to be the Administrator. During an interview with the administrator on 7/22/2024 at 3 p.m. and 7/24/2024, at 2 p.m, she stated she has a Bachelor's degree in Social work and that she used to work as an Administrator in a previous Hospice and that she is currently enrolled in California Associate For Health Services At Home (CAHSAH), for her administrators license. A review of the Electronic Licensing Management system (ELMS) for this hospice agency, indicated that the administrator role status was inactive since the start/end date of 9/8/2023. A review of the hospice agency's Electronic Licensing Management system (ELMS) indicated there was no documented evidence the administrator ever worked for or had an administrative role. A review of the Hospice agency's Job Description Titled, "Administrator" under Qualifications, stipulates the following: A person who is a licensed physician, or A registered Nurse Has training and experience in health service administration and at least two (2) years of supervisory or administrative experience in Hospice or related program.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation for Medical Director was met as follow: 1. The HA failed to ensure, the Medical Director conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial certifications for two of fourteen sampled patients (Patient 1 and Patient 11) to support the diagnosis of the patients' terminal illnesses (a health condition that cannot be cured) and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The HA failed to ensure there was documentation of clinical information that included the patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice care and services. (Refer to L669) --- This deficient practice resulted in the patient being enrolled in hospice and receiving care without a proper verification of patient eligibility and had the potential for Patient 1 and Patient 11 to not receive necessary care and healthcare resources to meet their care goals. (Refer to L667).

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 Medical Director conducted an accurate assessment, reviewed, and verified the patient's clinical information, necessary for Initial Certification of Terminal Illness (CTI) to support the diagnosis of the patients' terminal illnesses and to qualify for hospice care for two of fourteen sampled patients (Patient 1 and Patient 11). The HA had no documentation of clinical information that included the patients history and physicals, laboratory and imaging data, biopsy results, et cetera, necessary for initial certification of hospice care and services. This deficient practice resulted in patient's being enrolled in hospice and receiving care without a proper verification of the patient eligibility and had the potential for Patient 1, Patient 11 and Patient 12 to not receive necessary care and healthcare resources to meet their care goals. --- During a record review of Patient 11s Personal Information record indicated a start of care (SOC) date of 4/25/2024, with a primary diagnosis of end stage heart failure (a specific type of heart failure that occurs in the heart's left ventricle). During a record review of Patient 11s Physicians Certification for Hospice benefit Certification (CTI) #1: Statement for First 90-day period indicated primary diagnosis of end stage heart failure. The CTI further indicated under Physician Narrative, ";End stage heart failure- Patient with end stage heart failure in that he has symptoms of recurrent symptoms of chest pain and shortness of breath at rest along with discomfort with any activity. He is optimally treated with appropriate medications." During a review of Patient 11s ";LCD Hospice Eligibility Determination" (local coverage determination for Hospice eligibility used by national government services used to determine guidelines for terminally ill patients and if they have a life expectancy of six months or less), dated 4/26/2024, indicated for NYHA classification under A. Does this CHF (congestive heart failure, the heart's capacity to pump blood cannot keep up with the body's need the term congestive refers to the resulting buildup of fluids in the ankles and feet, arms, lungs, and or other organs), or angina patient meet the criteria for NYHA Class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort) level? Yes." The LCD guidelines also indicated patient has declined surgical procedure for the terminal diagnosis. During a phone interview on 7/23/2024 at 11:15 pm Patient 11s daughter, Patient 11s daughter stated, ";my father does not have any heart failure. The only heart related issue he has is high blood pressure. My dad can walk without having any shortness of breath on flat areas, if he has to go up a flight of stairs he might get a little short of breath because hes older. He can walk about a block with no assistance and no shortness of breath. He doesnt use any oxygen either." During a review of Patient 11s clinical record Progress Note from Medical Clinic, dated 4/3/2024, the Progress note indicated, ";Medical History: Type 2 Diabetes (a condition which results in poor circulation of blood sugar), Hypertension (high blood pressure), Hyperlipidemia ( high cholesterol levels in the blood), Acid Reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining), left toe amputation 3/2024." During a phone interview on 7/24/2024 at m 12:25pm, with Medical Director (MD), when asked what criteria MD uses to certifies patients for hospice, MD stated, ";information I receive from the nurses, I look at notes, talk to staff and go by LCD criteria. I look over what is scanned for history and physical and I go based on the nurses narrative because they see the patient." When asked if the primary care physician of the patient is contacted, MD stated, ";Sometimes if they already have the order than thats what I go by most of the time its from the hospital and its the hospital records." When asked if MD reviews any clinical documents for the patients before certifying for hospice, MD stated, ";any records I have, hospital records, last note, what the nurse saw." When asked what information is needed to diagnose a patient with end stage heart failure, MD stated." The notes and records, actual documented type of heart disease. Also lab tests, like BNP (Brain natriuretic peptide, blood test that measures the levels of a protein hormone in your bloodstream which is produced by the heart and blood vessels and higher levels and indicate heart inability to pump blood throughout the body or heart failure), blood pressure, edema, shortness of breath by just sitting there, echo (echocardiogram, ultrasound scan which uses sound waves to create pictures of the heart. This common test can show blood flow through the heart and the heart valves, which is used to find heart disease and other heart conditions), any history heart disease documents." When asked what criteria is used to determine NYHA class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort), MD stated, ";not able to carry any physical activity without discomfort, they will have, edema and cough varies but will have shortness of breath." When asked for Patient 11, what criteria was used to determine end stage heart failure and NYHA 4, MD stated, ";I went by the diagnosis the nurse listed in the CTI (certification of terminal illness) and talk to the nurse about Patient 11s symptoms. I usually do it based on what is verbally reported to me by the nurse and and times look at the notes. Doesnt look like Patient 11 qualifies for hospice based on the history and physical in the chart. I dont know where the nurse got the information from. Based on what I am looking at now this patient doesnt qualify for hospice. I am not sure if I had looked at history and physical before. I just took the nurses assessment. You have to interview the nurse. They put in the diagnosis in the system. They tell me hey this patient has End stage heart failure and they put it in the system. I just do the physician narrative. The nurses put the diagnosis and everything else in the system." During a concurrent interview and record review on 7/24/2024 at 2:50 pm with DPCS of Patient 11s CTI, DPCS stated, ";we discuss assessment with the medical director and input the diagnosis for the CTI. Based on what I see for Patient 11, the history and physical does not indicate any history of heart disease other than hypertension. And he only has metoprolol 25 mg (medication to lower high blood pressure) listed for hypertension. No other medications for heart disease." During a review of the HAs policy, titled ";Admission Criteria and Process," revised November 2020, indicated the following: - The HA will admit a patient only on recommendation of the medical director, in consultation with, or input from, the patients attending physician, if any. - The patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD. - The patient must desire hospice services and be aware of the diagnosis and prognosis. During a review of the HAs undated policy, titled ";Professional Services Agreement for Medical Director Designee," indicated the hospice Medical Director Designee will have overall responsibility for the medical component of the hospice program. The policy indicated the Medical Director Designees responsibilities included reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness. During a review of the HAs policy, titled ";Certification of Terminal Illness," revised November 2020, indicated the following: 1.At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election. 2. If written certification cannot be obtained within two (2) calendar days following the start of care, verbal certification must be obtained and documented in the clinical record within two (2) days following initiation of care and written certification must be obtained before the hospice submits a claim for payment. 3. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. Initially, the clinical information may be provided verbally, and must be documented in the clinical record and included as part of the hospice's eligibility assessment. 4. Both the attending physician's and Medical Director's signed and dated initial certification forms must be on file prior to billing the first claim. a. A review of Patient 12's Personal Information Sheet indicated Patient 12 was admitted to the hospice agency on 6/17/2024, with a terminal diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions).The clinical record further indicated the ";referring/attending/patient choice" physician was blank with no signature for the referring physician. A review of Patient 12s Physicians Certification for Hospice Benefit dated 6/17/2024 to 9/14/2024, Benefit Period #1, indicated Physician 1 signed the attending physician referral section to indicate Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 12s General Acute Care Hospital (GACH) record dated 6/15/2024, indicated Patient 12 was admitted due to weakness, and urinary tract infection, and that Patient 12 was alert and oriented, and stated age with no acute distress. There was no documented evidence of written clinical information being reviewed and evaluated to support the diagnosis of terminal illness that included the primary terminal condition, related diagnosis(es), current subjective and objective medical findings, current medication, and treatment orders; and information about the medical management of any of the patient's conditions unrelated to the terminal illness. There was no documentation for laboratory test result, imaging data, history and physical, and biopsy results that showed evidence to support the terminal illness diagnosis. a. A review of Patient 1s History and Physical, ";IP CM Active Discharge Planning" section from Hospital 1, dated 7/2/2024, which was provided by the HA to the survey team, indicated that Patient 1 was referred to Home Health Agency 1 (HHA 1) following discharge. The ";IP CM Active Discharge Planning" section indicated that the contact person from HHA 1, which is also the Administrator of the Hospice Agency, had confirmed acceptance of Patient 1 to HHA 1. The order for HHA 1 was as follows: Registered Nurse (RN) for wound care/medication management and Physical Therapy/Occupational Therapy. When the survey team called the phone number listed for HHA 1, the call went to the voicemail of the hospice agencys administrator. A review of Patient 1s ";Personal Information" indicated a start of care (SOC) date of 7/7/2024, with a primary diagnosis of acute (severe and sudden in onset) diastolic congestive heart failure (a condition in which the hearts main pumping chamber [left ventricle] becomes stiff and unable to fill properly). During a telephone interview with Patient 1 on 7/17/2024 at 10:10 a.m., Patient 1 stated he had never been diagnosed with a terminal illness by his physician, nor had his physician informed him that he had six months or less to live. Patient 1 stated he was currently on the waiting list to receive a kidney transplant. During a concurrent interview and record review with the Administrator (ADM) on 7/24/2024 at 2:30 p.m., the ADM stated Patient 1 was referred to HHA 1, which is a home health agency, and not to a hospice agency. The ADM stated she owned HHA 1. The ADM stated that she had admitted Patient 1 to the hospice agency without a physician order or physician referral. During a telephone interview with the Medical Director (MD) on 7/24/2024, at 12:20 p.m., the MD stated he certified a patient for hospice based on the LCD (Local Coverage Determination) criteria, History and Physical from the hospital, and the Registered Nurses narrative because they saw the patient first. When the MD was asked how Patient 1 was admitted to the hospice agency when the discharge instruction was to discharge to a home with home health, the MD stated he was not able to see the History and Physical from Hospital 1 on the electronic medical record. During the same interview, the MD stated the Registered Nurse was the one putting the diagnosis in the CTI, and he would write his narrative and then sign it. The MD stated he would base his narrative on what was verbally reported to him by the HAs Registered Nurse, who saw the patient. When the MD was asked what factors made him determine Patient 1s primary diagnosis as acute diastolic congestive heart failure, which was then changed to end stage heart failure, the MD stated he based it on what the nurses verbally reported to him. The MD stated, ";Maybe I see that he has end stage renal disease, then he has fluid overload, on dialysis, thats why I went with end stage heart failure. I dont know why I didnt use coronary artery disease. I wouldve used coronary artery disease." The MD stated that Patient 1 was not eligible under end stage heart failure diagnosis. During an interview with the Director of Patient Care Services (DPCS) on 7/24/2024, at 2 p.m., the DPCS stated she had been putting the patients diagnosis in their CTIs. The DPCS stated that she was aware she should not have been writing patients diagnosis as it was not within her scope of practice. A review of the HAs policy, titled ";Admission Criteria and Process," revised November 2020, indicated the following: - The HA will admit a patient only on recommendation of the medical director, in consultation with, or input from, the patients attending physician, if any. - The patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD. - The patient must desire hospice services and be aware of the diagnosis and prognosis. A review of the HAs undated policy, titled ";Professional Services Agreement for Medical Director Designee," indicated the hospice Medical Director Designee will have overall responsibility for the medical component of the hospice program. The policy indicated the Medical Director Designees responsibilities included reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing written certification of the terminal illness.

Based on interview and record review, the Hospice Agencys (HA, agency providing care to terminally ill patients who have six months or less to live) failed to assume responsibility for the medical component of the hospices patient care program for two of fourteen sampled patients (Patient 1 and Patient 11). This deficient practice resulted in patients being enrolled to the HA without oversight of the implementation of the hospice services to ensure the patients and patients familys needs were being met. --- During a record review of Patient 11s Personal Information record, the Personal Information record indicated a start of care (SOC) date of 4/25/2024, with a primary diagnosis of end stage heart failure (a specific type of heart failure that occurs in the heart's left ventricle). During a record review of Patient 11s Physicians Certification for Hospice benefit Certification (CTI) #1: Statement for First 90-day period, the Physician's Certification indicated a primary diagnosis of end stage heart failure. The CTI further indicated under Physician Narrative, ";End stage heart failure- Patient with end stage heart failure in that he has symptoms of recurrent symptoms of chest pain and shortness of breath at rest along with discomfort with any activity. He is optimally treated with appropriate medications." During a review of Patient 11s ";LCD Hospice Eligibility Determination" (local coverage determination for Hospice eligibility used by national government services used to determine guidelines for terminally ill patients and if they have a life expectancy of six months or less), dated 4/26/2024, indicated for NYHA classification under A. Does this CHF (congestive heart failure, the heart's capacity to pump blood cannot keep up with the body's need. The term congestive refers to the resulting buildup of fluids in the ankles and feet, arms, lungs, and or other organs), or angina patient meet the criteria for NYHA Class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that the patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort) level? Yes." The LCD guidelines also indicated patient has declined surgical procedure for the terminal diagnosis. During a phone interview on 7/23/2024 at 11:15 pm with Patient 11s daughter, Patient 11s daughter stated, ";My father does not have any heart failure. The only heart related issue he has is high blood pressure. My dad can walk without having any shortness of breath on flat areas, if he has to go up a flight of stairs he might get a little short of breath because hes older. He can walk about a block with no assistance and no shortness of breath. He doesnt use any oxygen either." During a review of Patient 11s clinical record Progress Note from the Medical Clinic, dated 4/3/2024, the Progress note indicated, ";Medical History: Type 2 diabetes (a condition which results in poor circulation of blood sugar), hypertension (high blood pressure), hyperlipidemia (high cholesterol levels in the blood), acid reflux (a digestive disease in which stomach acid or bile irritates the food pipe lining) and left toe amputation on 3/2024." During a phone interview on 7/24/2024 at 12:25pm, with the Medical Director (MD), when asked what criteria the MD uses to certifies patients for hospice, the MD stated, ";Information I receive from the nurses. I look at notes, talk to staff and go by the LCD criteria. I look over what is scanned for history and physical and I go based on the nurses narrative because they see the patient." When asked if the primary care physician of the patient is contacted, the MD stated, ";Sometimes if they already have the order than thats what I go by most of the time its from the hospital and its the hospital records." When asked if the MD reviews any clinical documents for the patients before certifying for hospice, the MD stated, ";Any records I have, hospital records, last note, what the nurse saw." When asked what information is needed to diagnose a patient with end stage heart failure, the MD stated. " The notes and records, actual documented type of heart disease. Also lab tests, like BNP (Brain natriuretic peptide, blood test that measures the levels of a protein hormone in your bloodstream which is produced by the heart and blood vessels and higher levels and indicate heart inability to pump blood throughout the body or heart failure), blood pressure, edema, shortness of breath by just sitting there, echo (echocardiogram, ultrasound scan which uses sound waves to create pictures of the heart. This common test can show blood flow through the heart and the heart valves, which is used to find heart disease and other heart conditions), any history heart disease documents." When asked what criteria is used to determine NYHA class 4 (New York Heart Association classification of heart failure, with class 4 being the most severe stage of heart failure and indicates that patient is unstable to perform any physical activity without discomfort. Patients with Class 4 heart failure experience symptoms even when resting or with minimal exertion, and any physical activity increases their discomfort), the MD stated, ";Not able to carry any physical activity without discomfort, they will have, edema and cough varies but will have shortness of breath." When asked for Patient 11, what criteria was used to determine end stage heart failure and NYHA 4, MD stated, ";I went by the diagnosis the nurse listed on the CTI (certification of terminal illness) and talked to the nurse about Patient 11s symptoms. I usually do it based on what is verbally reported to me by the nurse and and times look at the notes. Doesnt look like Patient 11 qualifies for hospice based on the history and physical in the chart. I dont know where the nurse got the information from. Based on what I am looking at now this patient doesnt qualify for hospice. I am not sure if I had looked at the history and physical before. I just took the nurses assessment. You have to interview the nurse. They put the diagnosis in the system. They tell me this patient has end stage heart failure and they put it in the system. I just do the physician narrative. The nurses put the diagnosis and everything else in the system." During a concurrent interview and record review on 7/24/2024 at 2:50 pm with DPCS of Patient 11s CTI, DPCS stated, ";We discuss assessment with the medical director and input the diagnosis for the CTI. Based on what I see for Patient 11, the history and physical does not indicate any history of heart disease other than hypertension. And he only has metoprolol 25 mg (medication to lower high blood pressure) listed for hypertension. No other medications for heart disease." During a review of the HAs policy, titled ";Admission Criteria and P process," revised November 2020, indicated the following: - The HA will admit a patient only on recommendation of the medical director, in consultation with, or input from, the patients attending physician, if any. - The patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD. - The patient must desire hospice services and be aware of the diagnosis and prognosis. During a review of the HAs undated policy, titled ";Professional Services Agreement for Medical Director Designee," indicated the hospice Medical Director Designee will have overall responsibility for the medical component of the hospice program. The policy indicated the Medical Director Designees responsibilities included reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness. a. A review of Patient 1s History and Physical, ";IP CM Active Discharge Planning" section from Hospital 1, dated 7/2/2024, which was provided by the HA to the survey team, indicated Patient 1 was referred to a Home Health Agency 1 (HHA 1) following discharge. The ";IP CM Active Discharge Planning" section indicated that the contact person from HHA 1, which is also the Administrator of the Hospice Agency, had confirmed acceptance of Patient 1 to HHA 1. The order for HHA 1 was as follows: Registered Nurse (RN) for wound care/medication management and Physical Therapy/Occupational Therapy. When the survey team called the phone number listed for HHA 1, the call went to the voicemail of the hospice agencys administrator. A review of Patient 1s ";Personal Information" indicated a start of care (SOC) date of 7/7/2024, with a primary diagnosis of acute (severe and sudden in onset) diastolic congestive heart failure (a condition in which the hearts main pumping chamber [left ventricle] becomes stiff and unable to fill properly). During a telephone interview with Patient 1 on 7/17/2024 at 10:10 a.m., Patient 1 stated he had never been diagnosed with a terminal illness by his physician, nor had his physician informed him that he had six months or less to live. Patient 1 stated he was currently on the waiting list to receive a kidney transplant. During a concurrent interview and record review with the Administrator (ADM) on 7/24/2024 at 2:30 p.m., the ADM stated Patient 1 was referred to HHA 1, which is a home health agency, and not to a hospice agency. The ADM stated she owned HHA 1. The ADM stated that she had admitted Patient 1 to the hospice agency without a physician order or physician referral. During a telephone interview with the Medical Director (MD) on 7/24/2024, at 12:20 p.m., the MD stated he certified a patient for hospice based on the LCD (Local Coverage Determination) criteria, History and Physical from the hospital, and the Registered Nurses narrative because they saw the patient first. When the MD was asked how Patient 1 was admitted to the hospice agency when the discharge instruction was to discharge home with home health, the MD stated he was not able to see the History and Physical from Hospital 1 on the electronic medical record. During the same interview, the MD stated the Registered Nurse was the one putting the diagnosis in the CTI, and he would write his narrative and then sign it. The MD stated he would base his narrative on what was verbally reported to him by the HAs Registered Nurse, who saw the patient. When the MD was asked what factors made him determine Patient 1s primary diagnosis as acute diastolic congestive heart failure, which was then changed to end stage heart failure, the MD stated he based it on what the nurses verbally reported to him. The MD stated, ";Maybe I see that he has end stage renal disease, then he has fluid overload, on dialysis, thats why I went with end stage heart failure. I dont know why I didnt use coronary artery disease. I wouldve used coronary artery disease." The MD stated that Patient 1 was not eligible under end stage heart failure diagnosis. During an interview with the Director of Patient Care Services (DPCS) on 7/24/2024, at 2 p.m., the DPCS stated she had been putting the patients diagnosis in their CTIs. The DPCS stated that she was aware she should not have been writing patients diagnosis as it was not within her scope of practice. A review of the HAs policy, titled ";Admission Criteria and Process," revised November 2020, indicated the following: - The HA will admit a patient only on recommendation of the medical director, in consultation with, or input from, the patients attending physician, if any. - The patient must have a life-limiting illness with a life expectancy of six months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD. - The patient must desire hospice services and be aware of the diagnosis and prognosis. A review of the HAs undated policy, titled ";Professional Services Agreement for Medical Director Designee," indicated the hospice Medical Director Designee will have overall responsibility for the medical component of the hospice program. The policy indicated the Medical Director Designees responsibilities included reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness.

Based on interview and record review, the hospice agency (HA; agency providing care to terminally ill patients) failed to ensure the Condition of Participation (condition that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for CLINICAL RECORDS was met as follows: --- 1. The hospice agency (HA) failed to ensure the clinical records included the routine visit notes that reflected the patients current health status and the care/treatment was provided for two out of 14 sampled patients (Patients 9 and 11). (Refer to L672). The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated Federal compliance for CLINICAL RECORDS which were not violated and that patients received quality hospice care.

The hospice agency (HA) failed to ensure the clinical records included the individualized plan of care, comprehensive assessment, and routine visit notes that reflected the patients current health status and the care and treatment was provided for four of 14 sampled patients (Patient 1, Patient 2, Patient 9, and Patient 11). As a result, Patient 1, Patient 2, Patient 9, and Patient 11 did not have completed clinical records that could potentially result in not identifying a change in the patients conditions and affect the patients care and services that could lead to hospitalization and death when clinical records did not include current, correct, and updated individualized plan of care, comprehensive assessment, and nursing visits notes of the patients. --- c. During a review of Patient 9s admission record, the admission record indicated a start of care (SOC) date of 7/12/2024, with a terminal diagnosis of cerebrovascular disease (end stage heart failure (a condition that affect blood flow and the blood vessels in the brain). During a review of Patient 9's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 7/12/2024, the POC indicated an order for SN (skilled nurse) to provide skilled nursing visits of once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). A further review of Patient 9's SN (skilled nurse) Visit Notes, indicated there was no SN visit notes found in the EMR (electronic medical records). During an interview on 7/16/2024, at 2 p.m., with the Administrator, she stated she could not provide a documented evidence of any nursing note visit submitted for Patient 9. d. During a review of Patient 11s admission record, the admission record indicated a start of care (SOC) date of 4/25/2024, with a terminal diagnosis of end stage heart failure (a specific type of heart failure that occurs in the heart's left ventricle). During a review of Patient 11's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 7/11/2024, the POC indicated an order for SN (skilled nurse) to provide skilled nursing visits of once a week and two as needed visits, and SC (spiritual counseling) within five days of admission for spiritual assessment). A review of Patient 11s History of RN (registered nurse) Visits, Patient 11s History of RN Visits, indicated there was no RN visit notes for the following dates of 5/10, 5/24/2024, 6/7/2024, 6/21/2024, and 7/5/2024. The history further indicated the SN visit note was blank and not completed at all. During an interview on 7/16/2024, at 2 p.m., with the Administrator, she stated she could not provide documented evidence of a nursing note for visit on 5/10/2024, 5/24/2024, 6/7/2024, 6/21/2024, and 7/5/2024. During a review of the HA's undated policy and procedure titled, ";Contents of Clinical Records", the records indicated ";Staff notes will be submitted within seven to 365 days of clinical visit date with patient from paper to EMR system." a. A review of Patient 1s ";Personal Information" indicated a start of care (SOC) date of 7/7/2024, with a primary diagnosis of acute (severe and sudden in onset) diastolic congestive heart failure (a condition in which the hearts main pumping chamber [left ventricle] becomes stiff and unable to fill properly). During a telephone interview with Patient 1 on 7/17/2024, at 10;10 a.m., Patient 1 stated that he had been on dialysis (a life-saving treatment for kidney failure that removes waste and extra fluids from the blood and regulates blood pressure) for six years. Patient 1 stated he had a fistula (a connection that was made between an artery [a blood vessel that carries blood from the heart to tissues and organs in the body] and a vein [a blood vessel that collects oxygen-poor blood and returns it to the heart] for dialysis access on his left upper arm. Patient 1 stated he went to dialysis three times a week. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 7/16/2024, at 3:10 p.m., the DPCS reviewed Patient 1s ";POC/IDG Review," (Plan of Care/Interdisciplinary Group Review, a written document that outlines the specific needs and services provided to a patient facing a terminal illness, which is reviewed and revised periodically by an interdisciplinary group of nurses, physicians, social workers, and counselors) dated 7/11/2024 and ";Plan of Care," dated 7/16/2024. The DPCS confirmed the ";IDG Discussion" and ";Plan of care" sections for Patient 1 were blank. The DPCS also confirmed that the POC/IDG review was not signed by IDG members, except for the Medical Director (MD). The DPCS stated that as of 7/16/2024, Patient 1 did not have any interventions and goals established. b. A review of Patient 2s ";Personal Information" indicated a start of care (SOC) date of 7/10/2024, with a primary diagnosis of end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest; symptoms may include shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]). During a concurrent record review and interview with the Director of Patient Care Services (DPCS) on 7/16/2024, at 2:50 p.m., the DPCS reviewed Patient 2s ";Comprehensive Nursing Assessment," dated 7/10/2024. The DPCS confirmed the Comprehensive Nursing Assessment was blank. The DPCS stated , "If it was not documented then it was not done. The DPCS also reviewed Patient 2s ";POC/IDG Review," dated 7/11/2024, and ";Plan of Care," dated 7/16/2024. The DPCS confirmed the ";IDG Discussion" and ";Plan of care" sections for Patient 2 were blank. The DPCS also confirmed that the POC/IDG review was not signed by IDG members, except for the Medical Director (MD). The DPCS stated that as of 7/16/2024, Patient 2 did not have any interventions and goals established. A review of the HAs policy, titled ";Clinical/Service Data Collection," dated 2018, indicated that entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the work day.

Based on interview and record review, the hospice agency (HA; agency providing care to terminally ill patients) failed to ensure the Condition of Participation (condition that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Personnel Qualification was met as follows: --- 1. The hospice agency (HA) failed to ensure a qualified Director of Patient Care Services (DPCS) was employed for ten out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patients 9, Patient 11, Patient 12, and Patient 14). (Refer to L784). 2. The HA failed to ensure a MSW (Masters in Social Work) was visiting two out of fourteen sampled patients (Patient 7, Patient 11, Patient 12). (Refer to L787) The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated Federal compliance for Personnel Qualification which were not violated and received quality hospice care.

Based on interview and record review, the HA failed to ensure a qualified DPCS was employed for ten out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patients 9, Patient 11, Patient 12, and Patient 14). The deficient practice had the potential to result in patients receiving substandard care. --- A. During a review of Patient 1s ";Personal Information" indicated a start of care (SOC) date of 7/7/2024, with a primary diagnosis of acute (severe and sudden in onset) diastolic congestive heart failure (a condition in which the hearts main pumping chamber [left ventricle] becomes stiff and unable to fill properly). B. During a review of Patient 2s ";Personal Information" indicated a SOC date of 7/10/2024, with a primary diagnosis of end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest; symptoms may include shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]). C. During a review of Patient 3s ";Personal Information" indicated a SOC date of 5/5/2024, with a primary diagnosis of end stage heart failure. D. During a review of Patient 4s ";Personal Information" indicated a SOC date of 7/10/2024, with a primary diagnosis of acute (severe and sudden in onset) and chronic (persistent for a long time or constantly recurring) respiratory failure (a condition that develops when the lungs cannot get enough oxygen into the blood) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). E. During a review of Patient 5s ";Personal Information" indicated a SOC date of 1/16/2024, with a primary diagnosis of heart disease, unspecified. F. During a review of Patient 8s ";Personal Information" indicated a SOC date of 7/13/2024, with a primary diagnosis of acute respiratory failure, unspecified with hypoxia, hypercapnia (a buildup of carbon dioxide in your bloodstream). G. During a review of Patient 10s ";Personal Information" indicated a SOC date of 7/2/2024, with a primary diagnosis of cerebrovascular disease (disease includes a variety of medical conditions that affect the blood vessels of the brain and the cerebral circulation), unspecified. H. During a review of Patient 11s ";Personal Information" , the information indicated a SOC date of 4/25/2024, with a primary diagnosis of end stage heart failure. I. During a review of Patient 12s ";Personal Information" indicated a SOC date of 5/5/2024, with a primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). J. During a review of Patient 14s ";Personal Information" indicated a SOC date of 5/5/2024, with a primary diagnosis of chronic ischemic heart disease, (a condition that occurs when the heart doesn't get enough blood and oxygen), unspecified. During a record review of DPCSs employee file indicated DPCS started working at the current HA 10/1/2023. During a review of DPCSs resume indicated DPCS had 2 months of hospice experience prior to her employment at the current hospice agency. During a record review of DPCSs California Board of Registered Nursing Licensing Details indicated DPCS initial RN license issuance date was 08/9/2023. During an interview on 7/22/2024 at 3:15 pm with DPCS, DPCS stated, ";I was an interim student RN in ICU (intensive care unit) and DOU (Direct observation unit) from December of 2020 to June of 2023. Then in August of 2023 I got my RN license. I did work as a case manager at a different hospice for about two months before I started working at this agency. I started working at this hospice agency in October of 2023 as a case manager then I was promoted to DPCS a few months later. Thats all of my nursing and hospice experience." During record review of HAs Job Description titled, ";Clinical Director/ Director of Patient Care Services", dated 1995, the job description indicated, ";Position Qualifications as follows: A. Three years of management experience within the last five years in a Hospice or related health care organization, at least one year of which was a supervisor in an administrative capacity. B. A registered nurse with four years experience within the last five years in a Hospice agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity.

Based on record review and interview, the hospice agency failed to ensure its socials workers met the qualifications required in Hospice for 14 of 14 sample patients. This deficient practice had the potential to result in patients not receiving psychosocial care and lack the ability to reach their highest quality of care and support. --- During a review of Patient 11s admission record, the admission record, indicated a start of care (SOC) date of 4/25/2024, with a terminal diagnosis of end stage heart failure (a specific type of heart failure that occurs in the heart's left ventricle). During a review of Patient 11's Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) dated 7/11/2024, the POC indicated a signature by the Administrator for the MSW (Masters in Social Work). During an interview on 7/24/2024 at 3:15 p.m. with Administrator, the Administrator stated, ";Yes I sign for the MSW because I have been visiting the patients and I am a medical social worker. I have my bachelors degree." During record review of the Administrator's employee file, the Administrator's education document, dated 11/13/2014, indicated a Bachelor's of Arts with a major in Psychology. During a record review of HAs Job Description titled, ";Social Worker/Social Work Associate/Associate Social Worker", revised 2022, the job description indicated, ";Position Qualifications as follows: 1. Graduate of a Master's or doctoral program in social work accredited by the Council on Social Work Education. Meets California requirements Section 1870 of California Code of Regulations. 2. Meets personnel qualifications stated in §418.114{b )(3)." During a review of Patient 1s ";Personal Information", the information indicated a start of care (SOC) date of 7/7/2024, with a primary diagnosis of acute (severe and sudden in onset) diastolic congestive heart failure (a condition in which the hearts main pumping chamber [left ventricle] becomes stiff and unable to fill properly). During a review of Patient 2s ";Personal Information" indicated a SOC date of 7/10/2024, with a primary diagnosis of end stage heart failure (the final and most severe stage of heart failure, during which time a person experiences symptoms, even while at rest; symptoms may include shortness of breath, fatigue, and heart arrhythmias [irregular heartbeat]). During a review of Patient 3s ";Personal Information" indicated a SOC date of 5/5/2024, with a primary diagnosis of end stage heart failure. During a review of Patient 4s ";Personal Information" indicated a SOC date of 7/10/2024, with a primary diagnosis of acute (severe and sudden in onset) and chronic (persistent for a long time or constantly recurring) respiratory failure (a condition that develops when the lungs cannot get enough oxygen into the blood) with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions). During a review of Patient 5s ";Personal Information" , the information indicated a SOC date of 1/16/2024, with a primary diagnosis of heart disease, unspecified. During a review of Patient 8s ";Personal Information" , the information indicated a SOC date of 7/13/2024, with a primary diagnosis of acute respiratory failure, unspecified with hypoxia, hypercapnia (a buildup of carbon dioxide in your bloodstream). During a review of Patient 10s ";Personal Information", the information indicated a SOC date of 7/2/2024, with a primary diagnosis of cerebrovascular disease (disease includes a variety of medical conditions that affect the blood vessels of the brain and the cerebral circulation), unspecified. During a review of Patient 11s ";Personal Information", the information indicated a SOC date of 4/25/2024, with a primary diagnosis of end stage heart failure. During a review of Patient 12s ";Personal Information", the information indicated a SOC date of 5/5/2024, with a primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a review of Patient 14s ";Personal Information" indicated a SOC date of 5/5/2024, with a primary diagnosis of chronic ischemic heart disease, (a condition that occurs when the heart doesn't get enough blood and oxygen), unspecified.

Observed in Document Review. In 1 of 3 contracts reviewed, The hospice nurse surveyor noted that the contractual agreement for general inpatient and respite care did not include a stipulation that the outside agency will complete criminal background checks on contracted employees who provide direct patient care or have access to patient records. This was confirmed with the hospice director.