Every finding on record at Ah Hospice, Inc.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Conditions of Participation (the terms healthcare organizations must meet to participate in federally funded healthcare programs) regarding Patients Rights was met as follows: 1. The HA failed to provide six of 14 sampled patients (Patient 2, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) information regarding their rights as a hospice patient in a language that would be understood and preferred by the patient. (Refer to L502) 2. The HA failed to inform seven of 14 sampled patients ((Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, Patient 11, and Patient 12)) about the services the HA provided and the limitations on those services. (Refer to L519) The cumulative effect of these systemic practice resulted in the failure of the hospice to deliver statutorily mandated Federal compliance for Patients Rights to ensure their rights are not violated and receive the highest quality of hospice care certified to receive the benefits.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure six of 14 sampled patients (Patient 2, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) were informed of their rights to be informed as hospice patients of the agency in a language that would be understood and preferred by these patients. This failure resulted in the patients not fully aware and understand their rights and responsibilities as patients of the hospice agency. --- Findings: a. During a review of Patient 8s admission record indicated a start of care (SOC) date of 2/3/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 2/14/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification, and the hospice aide to visit 2 times a week. During a review of the form ";Patient/Family Bill of Rights", signed by Patient 8 on 2/3/2024, indicated the form was in English. During a telephone interview on 5/9/2024 at 10:20 a.m. with Patient 8s family member (Patient 11), Patient 11 stated the consent forms and all other forms given to Patient 8 by the agencys nurse was in English. Patient 11 stated Patient 8s preferred language was Spanish and cannot read and does not understand the forms that he signed in front of the hospice nurse because it was in English. b. During a review of Patient 9s admission record indicated a SOC date of 9/20/2023 with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 9's POC/IDG form, dated 3/27/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor and social worker (MSW) to visit monthly and every recertification. The hospice aide service was declined. During a review of the form ";Patient/Family Bill of Rights", signed by Patient 9 on 9/20/2023, indicated the form was in English. During a joint home visit, on 5/9/2024 at 1:05 p.m. with the licensed vocational nurse (LVN 1) at Patient 9s residence, Patient 9 was observed awake, alert, oriented x 3 (to person, place and time), and ambulatory. During an interview, Patient 9 stated her preferred language was Spanish but all the forms that she signed with the hospice agency was in English. c. During a review of Patient 10s admission record indicated a SOC date of 3/23/2024 with a terminal diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery with unspecified angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 10's POC/IDG form, dated 3/27/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor and social worker (MSW) to visit monthly and every recertification, and hospice aide to visit two times a week. During a review of the form ";Patient/Family Bill of Rights", signed by Patient 10 on 3/23/2024, indicated the form was in English. During a telephone interview on 5/8/2024 at 3:35 p.m. with Patient 10s family member (FM 1), FM 1 stated the consent forms and all other forms signed by Patient 10 was in English. FM 1 stated Patient 10s preferred language was Spanish, and he cannot read and does not understand the forms that he signed because it was in English. d. During a review of Patient 11s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 11's POC/IDG form, dated 2/28/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor to visit monthly and as needed, MSW to perform an initial assessment within 5 days of admissions, and the hospice aide to visit 2 times a week. During a review of the form ";Patient/Family Bill of Rights", signed by Patient 11 on 2/21/2024, indicated the form was in English. During a telephone interview on 5/9/2024 at 10:20 a.m. with Patient 11, Patient 11 stated the consent forms and all other forms she signed with agency was in English. Patient 11 stated her preferred language was Spanish and she cannot read and does not understand the forms that she signed in front of the hospice nurse because it was in English. e. During a review of Patient 12s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 12's POC/IDG form, dated 2/28/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor to visit monthly and as needed, MSW to visit monthly and every recertification , and the hospice aide to visit 2 times a week. During a review of the form ";Patient/Family Bill of Rights", signed by Patient 12 on 2/21/2024, indicated the form was in English. During a joint home visit, on 5/8/2024 at 12:30 p.m. with the licensed vocational nurse (LVN 2) at Patient 12s residence, Patient 12 was observed awake, alert, oriented x 3 (to person, place and time), and ambulatory. During an interview, Patient 12 stated his preferred language was Spanish but all the forms that he signed with the hospice agency was in English. During an interview on 5/10/2024 at 1:15 p.m. with the acting Director of Patient Care Services (DPCS), DPCS stated the hospice forms including consent and patients Bill of Rights being provided to the patients should be in the language the patient understood. DPCS stated and acknowledged the finding. During a review of the agencys undated policy and procedure titled, ";Patient Bill of Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. The patient Bill of Rights/Responsibilities will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand. a. During a review of Patient 2s admission record indicated a start of care (SOC) date of 1/2/2024, with a terminal diagnosis of ischemic heart disease (damage or disease in the heart's major blood vessels). During a review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 1/16/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification, and the hospice aide to visit 2 times a week. On 5/8/2024, at 11 a.m., a home visit was conducted at Patient 2 with LVN1 (license vocational nurse). Patient 2 was observed awake, alert, oriented x 3 (to person, place and time), and ambulatory. During an interview, Patient 2 stated her preferred language was Spanish but all the forms that she signed with the hospice agency was in English.

Based on observation, interviews, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to inform seven of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, Patient 11, and Patient 12) about the services the HA provided and the limitations of these services. This deficient practice had resulted in the violation of the patients' rights to be fully informed about their hospice care services and its purpose. --- Findings: d. During a review of Patient 8s admission record indicated a start of care (SOC) date of 2/3/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 2/14/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification, and the hospice aide to visit 2 times a week. During a telephone interview on 5/9/2024 at 10:20 a.m. with Patient 8s family member (Patient 11), Patient 11 stated no doctors or nurses told Patient 8 he had 6 months or less to live and did not know that what he signed up for was for patients with terminal illness. Patient 11 stated nobody explained to Patient 8 what hospice care and services was nor he needs the service since he was not dying. e. During a review of Patient 9s admission record indicated a SOC date of 9/20/2023 with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 9's POC/IDG form, dated 3/27/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor and social worker (MSW) to visit monthly and every recertification. The hospice aide service was declined. During a joint home visit, on 5/9/2024 at 1:05 p.m. with the licensed vocational nurse (LVN 1) at Patient 9s residence, Patient 9 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory. During an interview, Patient 9 stated no doctors or nurses told her that she had 6 months or less to live, that nobody explained to her that what she signed up for was for hospice services, and she thought what she signed up for was for her to get free boxes of food, glucometer (a medical device for determining the approximate concentration of glucose in the blood), and blood pressure machine. f. During a review of Patient 11s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 11's POC/IDG form, dated 2/28/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor to visit monthly and as needed, MSW to perform an initial assessment within 5 days of admissions, and the hospice aide to visit 2 times a week. During a telephone interview on 5/9/2024 at 10:20 a.m. with Patient 11, Patient 11 stated no doctor or nurses told her that she had 6 months or less to live, and no one from the hospice agency explained to her that what she signed up was for hospice service, and for those patient with terminal illness. Patient 11 stated the consent form was in the language that she cannot read and understood, and that she signed it because of the promise by the agency staff to provide her with free boxes of food and medical equipment. g. During a review of Patient 12s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 12's POC/IDG form, dated 2/28/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor to visit monthly and as needed, MSW to visit monthly and every recertification , and the hospice aide to visit 2 times a week. During a joint home visit, on 5/8/2024 at 12:30 p.m. with the licensed vocational nurse (LVN 2) at Patient 12s residence, Patient 12 was observed awake, alert, oriented x 3 (to person, place and time), and ambulatory. During an interview, Patient 12 stated his preferred language was Spanish but all the forms that he signed with the hospice agency was in a language that he cannot read and did not understand. Patient 12 stated nobody explained to him that what he was signing up was for hospice services. Patient 12 stated he saw an ad from the agency in the grocery store offering free boxes of goods/fruits and medical devices and thinking that is what he was signing up for only. During a review of the agencys undated policy and procedure titled, ";Patient Bill of Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. The patient Bill of Rights/Responsibilities statement defines the right of the patient to be informed in advance of service about the care to be furnished, the organizations scope of services and services under the Medicare Hospice Benefit and any limitations on these services. a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 12/1/2024, with a terminal diagnosis of hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). During a review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 2/28/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification, and the hospice aide to visit 2 times a week. On 5/8/2024, at 12:30 p.m., a home visit was conducted at Patient 1's residence with LVN1 (license vocational nurse). Patient 1 was walking in steady gait (walking with balance) without using an assistive device (any kind of tool or device that can help simplify caregiving or make the environment safer). During an interview on 5/8/2024, at 12;45 p.m., with Patient 1, Patient 1 stated she did not have an idea what hospice services was about. Patient 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). Patient 1 stated the visiting nurse (unidentified) came and visited only once during the initial (first) visit. Patient 1 stated the HA offered to provide free medical supplies such as lotions, incontinent pads (absorbent pads), and shampoo upon patient admission to their hospice service. b. During a review of Patient 2s admission record indicated a start of care (SOC) date of 1/2/2024, with a terminal diagnosis of ischemic heart disease (damage or disease in the heart's major blood vessels). During a review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 1/16/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification, and the hospice aide to visit 2 times a week. On 5/8/2024, at 11 a.m., a home visit was conducted at Patient 2 with LVN1 (license vocational nurse). Patient 2 was observed awake, alert, oriented x 3 (to person, place and time), and ambulatory. During an interview on 5/8/2024, at 11:30 a.m., with Patient 2, Patient 2 stated the HA did not inform her about the purpose of the hospice care services. Patient 2 stated the HA would provide a nurse to visit every week to take her blood pressure and provide her with her prescribed medications. c. During a review of Patient 3s Admission Record, the Admission Record indicated a start of care (SOC) date of 1/24/2024, with a terminal diagnosis of ischemic cardiomyopathy (heart's decreased ability to pump blood properly). During a review of Patient 3's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 2/8/2024, the POC/IDG indicated the frequency of visits of licensed vocational nurse (LVN) to two visits per week, Registered Nurse (RN) to conduct an initial evaluation within five days of admission then every recertification. During a phone interview on 5/9/2024, at 11 a.m., with FM2 (family member), she stated the hospice agency did not inform Patient 3 regarding hospice services during his admission.

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of the Patient was met as follows: 1. The hospice agency failed to ensure the interdisciplinary group completed the comprehensive assessment no later than five calendar days after election of hospice care for four of 14 sampled patients (Patient 8, Patient 10, Patient 11, and Patient 12). (Refer to L523). 2. The hospice agency staff failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for eight of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). (Refer to L524). 3. The hospice agency failed to maintain an accurate, current medication profile for two of 14 sampled patients (Patient 2 and Patient 12). (Refer to L530). 4. The hospice agency failed to ensure interventions and reassessment for pain were implemented for two of 14 sampled patients (Patient 2 and Patient 11). (Refer to L533). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group completed the comprehensive assessment of the certified hospice patients no later than five calendar days after election for hospice care for four of 14 sampled patients (Patient 8, Patient 10, Patient 11, and Patient 12). This deficient practice had the potential to result in patients needs not being identified and appropriate care will not be provided affecting the hospice patient's quality of care and quality of life. --- Findings: a. During a review of Patient 8s admission record indicated a start of care (SOC) date of 2/3/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 2/3/2024, indicated the frequency of visits of the registered nurse (RN) to visit every 14 days for supervisory visit, licensed vocational nurse (LVN) to one visit per week and as needed, the spiritual counselor (SC) and social worker (MSW) to perform initial assessment within 5 days of admission, and the hospice aide to visit 2 times a week. During a review of Patient 8's Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), dated 2/3/2024, indicated Patient 8 was awake, alert, oriented x 2 (to place and person), had labored respirations (breathing), moderate dyspnea (shortness of breath) with mild exertion, and was dependent on cane or walker for ambulation. The Comprehensive Nursing Assessment was not signed by a registered nurse to indicate it was completed. b. During a review of Patient 10s admission record indicated a SOC date of 3/23/2024 with a terminal diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery with unspecified angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 10's POC/IDG form, dated 3/27/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor and social worker (MSW) to visit monthly and every recertification, hospice aide to visit two times a week, and the registered nurse to visit every 14 days for supervisory visit. During a review of Patient 10's Comprehensive Nursing Assessment, dated 3/23/2024, indicated Patient 10 was awake, alert, oriented x 2 (to place and person), had normal respirations, mild dyspnea with mild exertion, and required moderate assistance with ambulation, toileting and transfer, and maximum assistance with dressing and bathing. The Comprehensive Assessment was electronically signed by the previous Director of Patient Care Services (RN 1), on 5/8/2024, more than 6 weeks after the assessment was initially conducted. c. During a review of Patient 11s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 11's POC/IDG form, dated 2/21/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, MSW and the chaplain to perform an initial assessment within 5 days of admissions, the hospice aide to visit 2 times a week, and the registered nurse to visit every 14 days for supervisory visit. During a review of Patient 11's Comprehensive Nursing Assessment, dated 2/21/2024, indicated Patient 11 was awake, alert, oriented x 2 (to place and person), had normal respirations, moderate dyspnea with mild exertion, and required moderate assistance with ambulation, toileting and transfer, and maximum assistance with dressing and bathing. The Comprehensive Nursing Assessment was not signed by a registered nurse. d. During a review of Patient 12s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 12's POC/IDG form, dated 2/21/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, MSW and the chaplain to perform an initial assessment within 5 days of admissions, the hospice aide to visit 2 times a week, and the registered nurse to visit every 14 days for supervisory visit. During a review of Patient 12's Comprehensive Nursing Assessment, dated 2/21/2024, indicated Patient 12 was awake, alert, oriented x 3 (to time, place, and person), had normal respirations, moderate dyspnea with mild exertion, and required moderate assistance with ambulation, toileting, transfer, and dressing, and maximum assistance with bathing. The Comprehensive Assessment was electronically signed by the previous Director of Patient Care Services, on 5/8/2024, 2 ½ months after the assessment was conducted. During a concurrent interview and record review, on 5/10/2024 at 1:15 p.m., with the acting Director of Patient Care Services (DPCS), DPCS stated comprehensive assessment should be completed, documented, and signed within 5 days from the start of hospice care and service. DPCS confirmed Patient 8, Patient 10, Patient 11, and Patient 12s comprehensive nursing assessment was not completed within 5 days from the start of care of hospice service. During a telephone interview with RN 1, on 5/10/2024 at 2:35 p.m., when asked if he signed and completed Patient 10 and Patient 12s comprehensive nursing assessment on 5/8/2024, RN 1 stated he did not. RN 1 stated he resigned from the hospice agency effective date 4/30/2024 and does not have access anymore to the agencys electronic patient records. During a review of the agencys undated policy and procedure titled, ";Initial and Comprehensive Assessment," indicated an initial patient assessment will be performed and documented in the patients clinical record by a registered nurse, physical therapist, occupational therapist or speech therapist. A comprehensive patient assessment will be completed within 5 calendar days of the patients start of care.

Based on observation, interview, and record review, the Hospice Agency (HA) staff failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for eight out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This deficient practice has the potential to result in the hospice certifying patients who did not need hospice care and service management of terminal illness and had the potential to result in the patients not receiving appropriate healthcare services that could affect their quality of life. --- Findings: d. During a review of Patient 8s admission record indicated a start of care (SOC) date of 2/3/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 8's Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), dated 2/3/2024, indicated Patient 8 was awake, alert, oriented x 2 (to place and person), had labored respirations (breathing), moderate dyspnea (shortness of breath) with mild exertion, and was dependent on cane or walker for ambulation. The Comprehensive Nursing Assessment was not signed by a registered nurse. During a review of Patient 8's Certification of Terminal Illness (or CTI, Physician's certification of the patient being terminally ill to have Medicare hospice benefit), dated 4/26/2024, the Medical Director (Physician 1) indicated Patient 8 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. The ";Medical History and Prognosis of the Illness" section indicated Patient 8 had increasing disabling dyspnea at rest and was poorly responsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways) resulting in decreased functional capacity. During a review of Patient 8s LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) Hospice Eligibility Determination form for Pulmonary Disease, dated 2/3/2024, indicated Patient 8 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 should be met. It was marked "yes" in section 1 that Patient 8 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. It was marked ";yes" in section 2 that Patient 8 had O2 sat (oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95–100%) less than or equal to 88% determined either by arterial blood gases (a test that measures the oxygen and carbon dioxide levels in your blood) or O2 sat monitors. During a review of Patient 8's clinical record indicated there was no documented evidence Patient 8 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, or had O2 saturation of 88% or less prior to hospice admission. On 5/8/2024 at 11:00 a.m., an attempted home visit with the licensed vocational nurse (LVN 2) was scheduled at Patient 8s residence. While on the way to Patient 8s residence, surveyor received a message from LVN 2 that Patient 8 cancelled the visit because of a family emergency. During a telephone interview on 5/9/2024 at 10:20 a.m. with Patient 8s family member (Patient 11), Patient 11 stated Patient 8 was doing fine, never had shortness of breath at rest, and takes bronchodilator medication for years that helped relieve his respiratory symptoms like wheezing. Patient 11 further stated Patient 8 does not have terminal illness, have no family emergency and was available for a visit the day before. During an interview on 5/10/2024 at 1:15 p.m. with the acting Director of Patient Care Services (DPCS), DPCS stated he was not able to find documented evidence Patient 8 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, or had O2 saturation of 88% or less prior to hospice admission. e. During a review of Patient 9s admission record indicated a SOC date of 9/20/2023 with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 9's Recertification (Re-Cert) Assessment, dated 3/18/2024, indicated Patient 9 was awake, alert, oriented x 3 (person, place, time), had cardiac-related pain, normal respirations, moderate dyspnea (difficult or labored breathing) with mild exertion, and requires maximum assistance with ambulation, toileting, and transfer. The Re-Cert Assessment also indicated Patient 9 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure and met LCD guidelines for hospice eligibility. During a review of Patient 9s CTI, dated 3/13/2024, the Physician 1 indicated Patient 9 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. During a review of Patient 9s LCD Hospice Eligibility Determination form for Heart Disease, dated 3/18/2024, indicated Patient 9 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 1 has been ruled out as a candidate or has declined surgical procedures. Section 2 was marked "yes" that Patient 9s heart disease met the criteria for NYHA Class IV level. During a review of Patient 9's clinical record indicated there was no documented evidence Patient 9 had been ruled out as a candidate or had declined surgical procedures. There was also no documented evidence Patient 9 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest, or had an ejection fraction of less than 20. During a joint home visit, on 5/9/2024 at 1:05 p.m. with the licensed vocational nurse (LVN 1) at Patient 9s residence, Patient 9 was observed walking steadily from the door of her home to the front gate of the apartment building without the use of an assistive device, has no shortness of breath and did not complain of any chest pain. During an interview, Patient 9 stated no doctors or nurses told her that she had 6 months or less to live, that nobody explained to her that what she signed up for was for hospice services, and she thought what she signed up for was for her to get free boxes of food, glucometer (a medical device for determining the approximate concentration of glucose in the blood), and hygiene products. Patient 9 stated her own primary attending physician did not refer her to hospice care, that she had no terminal illness, not confined to bed or chair, and that she called the agency several times to discharge her from hospice service, but later found out that the agency kept on reinstating her for hospice care. During an interview on 5/10/2024 at 1:15 p.m. with the acting DPCS, DPCS stated he was not able to find documented evidence Patient 9 had been ruled out as a candidate or had declined surgical procedures. DPCS stated there was no documented evidence Patient 9 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. f. During a review of Patient 10s admission record indicated a SOC date of 3/23/2024 with a terminal diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery with unspecified angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 10's Comprehensive Nursing Assessment, dated 3/23/2024, indicated Patient 10 was awake, alert, oriented x 2 (to place and person), had normal respirations, mild dyspnea with mild exertion, and required moderate assistance with ambulation, toileting and transfer, and maximum assistance with dressing and bathing. The Comprehensive Assessment also indicated Patient 10 was on NYHA IV stage of heart failure, and met LCD guidelines for hospice eligibility. During a review of Patient 10s CTI, dated 3/23/2024, Physician 1 certified Patient 10 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 10 had a life expectancy of six months or less if the terminal illness runs its normal course. The narrative section did not indicate any documented and supporting evidence from the Medical Director that included laboratory test results, imaging data, and history and physical prior to hospice admission to support Patient 10s terminal illness diagnosis. During a review of Patient 10s LCD Hospice Eligibility Determination form for Heart Disease, dated 3/23/2024, indicated Patient 10 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 10 had declined surgical procedures. Section 2 was marked "yes" that Patient 10s heart disease met the criteria for NYHA Class IV level. During a review of Patient 10's clinical record indicated there was no documented evidence Patient 10 had declined surgical procedures. There was also no documented evidence Patient 10 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 5/8/2024 at 3:35 p.m. with Patient 10s family member (FM 1), FM 1 stated Patient 10 was independent, was not confined to bed or chair, walks to the store several times a week, and does not have terminal illness. During an interview on 5/10/2024 at 1:15 p.m. with the acting DPCS, DPCS stated he was not able to find documented evidence Patient 10 had had declined surgical procedures. DPCS stated there was no documented evidence Patient 10 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. g. During a review of Patient 11s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 11's Comprehensive Nursing Assessment, dated 2/21/2024, indicated Patient 11 was awake, alert, oriented x 2 (to place and person), had normal respirations, moderate dyspnea with mild exertion, and required moderate assistance with ambulation, toileting and transfer, and maximum assistance with dressing and bathing. The Comprehensive Assessment also indicated Patient 11 was on NYHA IV stage of heart failure and met LCD guidelines for hospice eligibility. The Comprehensive Nursing Assessment was not signed by a registered nurse. During a review of Patient 11s CTI, dated 2/21/2024, Physician 1 certified Patient 11 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. The narrative section did not indicate any documented and supporting evidence from the Medical Director that included laboratory test results, imaging data, and history and physical prior to hospice admission to support Patient 11s terminal illness diagnosis. During a review of Patient 11s LCD Hospice Eligibility Determination form for Heart Disease, dated 2/21/2024, indicated Patient 11 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 11 had declined surgical procedures. Section 2 was marked "yes" that Patient 11s heart disease met the criteria for NYHA Class IV level. During a review of Patient 11's clinical record indicated there was no documented evidence Patient 11 had declined surgical procedures. There was also no documented evidence Patient 11 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 5/9/2024 at 10:20 a.m. with Patient 11, Patient 11 stated no doctor or nurses told her that she had 6 months or less to live, and no one from the hospice agency explained to her that what she signed up was for hospice service, and for those patient with terminal illness. Patient 11 stated she was not confined to be or chair, was fully independent, goes to the market couple of times a week, does not have terminal illness, and requested to be removed from hospice care. During an interview on 5/10/2024 at 1:15 p.m. with the acting DPCS, DPCS stated he was not able to find documented evidence Patient 11 had had declined surgical procedures. DPCS stated there was no documented evidence Patient 11 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. h. During a review of Patient 12s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 12's Comprehensive Nursing Assessment, dated 2/21/2024, indicated Patient 12 was awake, alert, oriented x 3 (to time, place, and person), had normal respirations, moderate dyspnea with mild exertion, and required moderate assistance with ambulation, toileting, transfer, and dressing, and maximum assistance with bathing. The Comprehensive Assessment also indicated Patient 12 was on NYHA IV stage of heart failure and met LCD guidelines for hospice eligibility. During a review of Patient 12s CTI, dated 2/21/2024, Physician 1 certified Patient 12 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. The narrative section did not indicate any documented and supporting evidence from the Medical Director that included laboratory test results, imaging data, and history and physical prior to hospice admission to support Patient 12s terminal illness diagnosis. During a review of Patient 12s LCD Hospice Eligibility Determination form for Heart Disease, dated 2/21/2024, indicated Patient 12 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 12 had declined surgical procedures. Section 2 was marked "yes" that Patient 12s heart disease met the criteria for NYHA Class IV level. During a review of Patient 12's clinical record indicated there was no documented evidence Patient 12 had declined surgical procedures. There was also no documented evidence Patient 12 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a joint home visit, on 5/8/2024 at 12:30 p.m. with the licensed vocational nurse (LVN 2) at Patient 12s residence, Patient 12 was observed awake, alert, oriented x 3 (to person, place and time), and ambulatory. During an interview, Patient 12 stated nobody from the hospice agency explained to him that what he was signing up was for hospice services. Patient 12 stated he saw an ad from the agency in the grocery store offering free boxes of goods/fruits and medical devices and thinking that is what he was signing up for only. Patient 12 further stated he walked independently one hour in the morning and one hour in the afternoon to keep fit, had never had symptoms of heart disease, visits his primary physician regularly, and does not have terminal illness. During an interview on 5/10/2024 at 1:15 p.m. with the acting DPCS, DPCS stated he was not able to find documented evidence Patient 12 had had declined surgical procedures. DPCS stated there was no documented evidence Patient 12 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a review of the agencys undated policy and procedure titled "Admission Criteria and Process", indicated AH Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). AH Hospice Inc will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. During a review of the agencys undated policy and procedure titled ";Certification of Terminal Illness", indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 12/1/2024, with a terminal diagnosis of hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 12/1/23 to 2/28/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. 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 (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. On 5/8/2024, at 12:30 p.m., a home visit was conducted at Patient 1's residence with LVN1 (license vocational nurse). Patient 1 was walking in steady gait (walking with balance) without using an assistive device (any kind of tool or device that can help simplify caregiving or make the environment safer). During an interview on 5/8/2024, at 12;45 p.m., with Patient 1, Patient 1 stated she did not have an idea what hospice services was about. Patient 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). Patient 1 stated the visiting nurse (unidentified) came and visited only once during the initial (first) visit. Patient 1 stated the HA offered to provide free medical supplies such as lotions, incontinent pads (absorbent pads), and shampoo upon patient admission to their hospice service. b. During a review of Patient 2s admission record indicated a start of care (SOC) date of 1/2/2024, with a terminal diagnosis of ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 1/2/2024 to 3/31/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. 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 (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. On 5/8/2024, at 11 a.m., a home visit was conducted at Patient 2 with LVN1 (license vocational nurse). Patient 2 was observed awake, alert, oriented x 3 (to person, place and time), and ambulatory. During an interview on 5/8/2024, at 11:30 a.m., with Patient 2, Patient 2 stated the HA did not inform her about the purpose of the hospice care services. Patient 2 stated the HA would provide a nurse to visit every week to take her blood pressure and provide her with her prescribed medications. c. During a review of Patient 3s Admission Record, the Admission Record indicated a start of care (SOC) date of 1/24/2024, with a terminal diagnosis of ischemic cardiomyopathy (heart's decreased ability to pump blood properly). A review of Patient 3's Physicians Certification for Hospice Benefit, dated 1/24/2024 to 4/20/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. 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 (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a phone interview on 5/9/2024, at 11 a.m., with FM2 (family member), she stated the hospice agency did not inform Patient 3 regarding hospice services during his admission and Patient 3 was not sick and dying in six months.

Based on observation, interview and record review, the hospice agency (HA) failed to maintain an accurate, current medication profile for two of 14 sampled patients (Patients 2 and Patient 12). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. --- Findings: c. During a review of Patient 12s admission record indicated a start of care date of 2/21/2024, with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 12's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 2/28/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor to visit monthly and as needed, MSW (social worker) to visit monthly and every recertification, and the hospice aide to visit 2 times a week. During a joint home visit, on 5/8/2024 at 12:30 p.m. with the licensed vocational nurse (LVN 2) at Patient 12s residence, Patient 12 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory. On 5/8/2024, at 12:50 p.m., during a review of Patient 12s current medications with LVN 2, the following medications could not be found: 1. Acetaminophen 500 mg (milligrams) 1-2 tablets by mouth every 4-6 hours as needed for pain, 2. Aspirin 81 mg 1 tablet by mouth one time a day, 3. Furosemide 20 mg 1 tablet by mouth one time a day as needed for edema/swelling. However, Patient 12s current medication profile provided by the HA indicated he was currently taking these medications. During a concurrent interview with Patient 12, he stated he was not in pain and his primary physician stopped prescribing these medications for a couple of months. During an interview on 5/10/2024 at 1:15 p.m. with the acting Director of Patient Care Services (DPCS), DPCS stated hospice nursing staff need to review patients current medication on every visit and update the medication profile in the patients clinical record immediately. During a review of the hospice agencys undated policy and procedure titled, ";Medication Profile/Reconciliation", indicated patients receiving medications will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications. a. During a review of Patient 2s admission record indicated a start of care (SOC) date of 1/2/2024, with a terminal diagnosis of ischemic heart disease (damage or disease in the heart's major blood vessels). During a review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 1/16/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification, and the hospice aide to visit 2 times a week. A review of Patient 2's Current Treatment/Medication list indicate a prescribed order dated 1/10/2024, for Diclofenac Sodium one percent topical gel, to apply thin layer (2 gm) to affected area two to three times a day as needed for pain. On 5/8/2024, at 11 a.m., a home visit was conducted at Patient 2 with LVN1 (license vocational nurse). Patient 2 was observed awake, alert, oriented x 3 (to person, place and time), and ambulatory. On 5/8/2024, at 11 :30 a.m., during a review of Patient 2s current medications with LVN 1, the Diclofenac Sodium one percent topical gel medication was not found. On 5/8/2024, at 11:50 a.m., during an interview with Patient 2, she stated she ran out of the Diclofenac gel for a week and the visiting nurse told her she ordered the medication from the pharmacy and Patient 2 was still waiting to arrive. During an interview on 5/10/2024 at 2:15 p.m. with the acting Director of Patient Care Services (DPCS), DPCS stated hospice nursing staff need to review patients current medication on every visit.

Based on interview and record review, the hospice agency (HA) failed to ensure interventions and reassessment for pain were implemented for two of 14 sampled patients (Patients 2 and Patient 11). This deficient practice has the potential to result in an ineffective pain management. --- Findings: b. During a review of Patient 11s admission record indicated a start of care date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 3/27/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor to visit monthly and as needed, MSW (social worker) to perform an initial assessment within 5 days of admissions, and the hospice aide to visit 2 times a week. A care plan was initiated titled ";Pain" due to patients increasing pain with the disease process. The goal indicated that in 2 weeks and onwards, adequate pain relief measure will be provided, and pain will be at comfortable level 0-2/10 (on a pain scale of 0-10, 0 = no pain, 10 = unbearable pain). The care plan interventions indicated to assess/monitor pain and severity every visit, instruct family/caregiver (pcg) to give pain medications when pain level is greater than 3 or above, instruct on non-pharmacological methods of pain and symptom relief of repositioning, music therapy and/or calm quiet environment, and resolve pain with medications ordered. During a review of ";Visit Note LVN (licensed vocational nurse), dated 3/27/2024, indicated Patient 11 reported lower back pain, bilateral knees and ankle pain 4 out of 10. There was no documented evidence of interventions and reassessment done for the pain. During an interview on 5/10/2024 at 1:15 p.m. with the acting Director of Patient Care Services (DPCS), DPCS stated pain assessment should include pain intervention that was implemented and the effectiveness of the intervention. The DPCS acknowledged that in the case for Patient 1 and Patient 11, it was not done. During a review of the agencys undated policy and procedure titled, "Pain Assessment", indicated each patient will receive at least an initial pain assessment. When the patient or the clinician identifies pain, the following in-depth pain assessment information will be obtained whenever possible: pain intensity using a rating scale (on a scale of 0 – 10: 0=no pain; 10=unbearable pain), pain location, present pain management regimen and effectiveness, and physical exam or observation of the site of pain. During a review of Patient 2s admission record indicated a start of care (SOC) date of 1/2/2024, with a terminal diagnosis of ischemic heart disease (damage or disease in the heart's major blood vessels). During a review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 1/16/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly and every recertification, and the hospice aide to visit 2 times a week. On 5/8/2024, at 11 a.m., a home visit was conducted at Patient 2 with LVN1 (license vocational nurse). Patient 2 was observed awake, alert, oriented x 3 (to person, place and time), and ambulatory. On 5/8/2024, at 11:45 a.m., during an interview with Patient 2, she stated she had 7 to 8 out of 10 pain scale at lower back everyday and when she takes her prescribed pain medications, it relieved the pain temporarily. A review of Patient 2's Visit Note LVN (licensed vocational nurse) from dates 3/4/2024 to 5/1/2024, indicated no documented evidence of pain assessments done for lower back pain during visits.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary), Care Planning, and Coordination of Services was met as follows: 1. The hospice agency failed to ensure the IDG meetings were held by all the members of interdisciplinary group to discuss the patients comprehensive and ongoing assessments and care planning process for 5 out of 14 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). (Refer to L541) 2. The hospice agency failed to ensure home visits were conducted in accordance with the plan of care for three of 14 sampled patients (Patient 9, Patient 11, and Patient 12). (Refer to L555) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care was provided to the patients who were assessed to receive hospice care and services.

Based on interview and record review, the hospice agency (HA) failed to ensure the interdisciplinary group (IDG) meetings were held by all the members of interdisciplinary group to discuss the patients comprehensive and ongoing assessments and care planning process for 5 out of 14 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This deficient practice has a potential for the patients progress or decline will not be identified by the IDG, interventions will not be implemented, and patient care goals will not be achieved. --- Findings: a. During a review of Patient 8s admission record indicated a start of care (SOC) date of 2/3/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 3/27/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to one visit per week, the spiritual counselor (SC) and social worker (MSW) to visit monthly, every recertification and as needed, and the hospice aide to visit 2 times a week. During a review of Patient 8s POC/IDG meeting records indicated Physician 1 (Medical Director) and the registered nurse did not attend the meeting on 4/10/2024, and the Physician 1, registered nurse and chaplain did not attend the IDG meeting on 4/24/2024. b. During a review of Patient 9s admission record indicated a SOC date of 9/20/2023 with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 9's POC/IDG form, dated 3/27/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor and social worker to visit monthly and every recertification. The hospice aide service was declined. There was no documented evidence Physician 1 attended the IDTG meeting. During a review of Patient 9s POC/IDG meeting records indicated Physician 1 and the registered nurse did not attend the meetings on 4/10/2024 and 4/24/2024. c. During a review of Patient 10s admission record indicated a SOC date of 3/23/2024 with a terminal diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery with unspecified angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 10's POC/IDG meeting form, dated 3/27/2024, 4/10/2024 and 4/24/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor and social worker (MSW) to visit monthly and every recertification, and hospice aide to visit two times a week. The forms were not signed by all IDG members (Physician 1, registered nurse, social worker, and the chaplain). d. During a review of Patient 11s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 11's POC/IDG form, dated 2/28/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor to visit monthly and as needed, MSW to perform an initial assessment within 5 days of admissions, and the hospice aide to visit 2 times a week. During a review of Patient 11s POC/IDG meeting records indicated Physician 1 and the registered nurse did not attend the IDG meeting on 4/10/2024, and Physician 1, registered nurse and chaplain did not attend the meeting on 4/24/2024. e. During a review of Patient 12s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 12's POC/IDG form, dated 2/28/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor to visit monthly and as needed, MSW to visit monthly and every recertification, and the hospice aide to visit 2 times a week. During a review of Patient 12s POC/IDG meeting records indicated Physician 1 and the registered nurse did not attend the meetings on 4/10/2024 and 4/24/2024. During an interview on 5/10/2024 at 1:15 p.m. with the acting Director of Patient Care Services (DPCS), DPCS stated the IDG meeting is done every two weeks, and the members include the Medical Director, Social Worker, Chaplain, and DPCS/Registered Nurse. The DPCS stated members who attended the meeting either physically sign in person, or electronically. DPCS further stated the IDG meetings should be signed on the same day the meeting was held. The hospice agency was not able to provide documented evidence all the IDG members had participated in the IDG meetings for Patients 8, 9, 10, 11, and 12 on the indicated IDG dates. There was no documented evidence the hospice Physician 1 met with the other qualified professionals, and other members of the IDG to coordinate services provided to the hospice patients during the IDG meeting in order to discuss patients progress or changes and updates to the plan of care utilizing the results from the ongoing comprehensive assessments from each IDG members. During a review of the agency's policy and procedure titled, "Interdisciplinary Group Meeting," revised November 2021, indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor.

Based on observation, interviews and record review, the hospice agency failed to ensure home visit was conducted in accordance with the plans of care (POC) for three of 14 sampled patients (Patient 9, Patient 11, and Patient 12). This failure had the potential to negatively affect the patients' physical comfort, psychosocial well-being, and not receiving the identified needs and services timely. --- Findings: a. During a review of Patient 9s admission record indicated a start of care (SOC) date of 9/20/2023 with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 9's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 3/27/2024, indicated the frequency of visits of licensed vocational nurse (SN) to one visit per week and as needed, for ongoing assessments of all body systems, to assess monitor/assess effectiveness of current and new medication/treatment, and assess safety concerns/issues. During a review of Patient 9s SN Visit Notes calendar for the month of March 2024 and April 2024, indicated the agencys skilled nurses visited the patient at least once a week. During a joint home visit, on 5/9/2024 at 11 a.m., with a licensed vocational nurse (LVN 1) at Patient 9s residence, Patient 9 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without the use of an assistive device. During an interview with Patient 9, on 5/9/2024 at 11:30 a.m., Patient 9 stated she was only visited by the agencys SN once every 2 to 3 weeks. When asked that per the agencys electronic health records that she was visited by the agencys SN every week per the plan of care, Patient 9 stated, ";that is not true." b. During a review of Patient 11s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 11's POC/IDG form, dated 2/28/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, for ongoing assessments of all body systems, to assess monitor/assess effectiveness of current and new medication/treatment, and assess safety concerns/issues. During a review of Patient 11s SN Visit Notes for the month of April 2024, indicated the agencys skilled nurses visited the patient at least once a week. During a telephone interview, on 5/9/2024 at 10:20 a.m., with Patient 11, she stated she was not visited by the agencys SN for more than a month. c. During a review of Patient 12s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 12's POC/IDG form, dated 2/28/2024, indicated the frequency of visits of SN to one visit per week and as needed, for ongoing assessments of all body systems, to assess monitor/assess effectiveness of current and new medication/treatment, and assess safety concerns/issues. During a review of Patient 12s SN Visit Notes for the month of April 2024, indicated the agencys skilled nurses visited the patient at least once a week. During a joint home visit, on 5/8/2024 at 12:30 p.m., with a licensed vocational nurse (LVN 2) at Patient 12s residence, Patient 12 was observed awake, alert, oriented x 3, and ambulatory without the use of an assistive device. During an interview with Patient 12, on 5/8/2024 at 12:55 p.m., Patient 12 stated he was not visited by the agencys SN for about a month. During a concurrent interview and record review, on 5/10/2024 at 12:50 p.m., with the licensed vocational nurse case manager (CM 1), CM 1 stated per the agencys clinical records. Patient 9, Patient 11 and Patient 12 had SN clinical visit notes once a week submitted by the assigned SN. A request was made from CM 1 to provide route sheets (a form signed by the patient certifying the time work by the agency nurse) for Patient 9, 11, and 12, however; the hospice agency was unable to provide the route sheets requested for Patients 9, 11 and 12. During an interview on 5/10/2024 at 2:45 p.m., with the acting Director of Patient Care Services (DPCS), DPCS acknowledged the findings and stated patient care visit should be provided to patients in accordance with the plan of care. During a review of the agency's policy and procedure titled, "The Plan of Care", revised November 2021, 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.

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 (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Medical Director was met as evidenced by: --- The hospice agency (HA) failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), 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 and services for eight out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). (Refer to L667). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory (written rules or law) mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services. 1. The hospice agency failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice care and services for seven out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 10, Patient 11, and Patient 12). (Refer to L667) 2. The hospice agency failed to ensure the Medical Director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for one of 14 sampled patients (Patient 9). (Refer to L668) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory (written rules or law) mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), 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 and services for seven out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, Patient 10, Patient 11, and Patient 12). This deficient practice resulted in Patients 1, 2, 3, 8, 10,11, and 12, being certified and admitted for hospice care with no documented evidence of patients written clinical information was being reviewed and evaluated by the Medical Director and/or physician designee to support their diagnoses of terminal illness. --- d. During a review of Patient 8s admission record indicated a start of care (SOC) date of 2/3/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 8's Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), dated 2/3/2024, indicated Patient 8 was awake, alert, oriented x 2 (to place and person), had labored respirations (breathing), moderate dyspnea (shortness of breath) with mild exertion, and was dependent on cane or walker for ambulation. The Comprehensive Nursing Assessment was not signed by a registered nurse. During a review of Patient 8's Certification of Terminal Illness (or CTI, Physician's certification of the patient being terminally ill to have Medicare hospice benefit), dated 4/26/2024, the Medical Director (Physician 1) indicated Patient 8 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. The ";Medical History and Prognosis of the Illness" section indicated Patient 8 had increasing disabling dyspnea at rest and was poorly responsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways) resulting in decreased functional capacity. During a review of Patient 8s LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) Hospice Eligibility Determination form for Pulmonary Disease, dated 2/3/2024, indicated Patient 8 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 should be met. It was marked "yes" in section 1 that Patient 8 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. It was marked ";yes" in section 2 that Patient 8 had O2 sat (oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95–100%) less than or equal to 88% determined either by arterial blood gases (a test that measures the oxygen and carbon dioxide levels in your blood) or O2 sat monitors. During a review of Patient 8's clinical record indicated there was no documented evidence Patient 8 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, or had O2 saturation of 88% or less prior to hospice admission. On 5/8/2024 at 11:00 a.m., an attempted home visit with the licensed vocational nurse (LVN 2) was scheduled at Patient 8s residence. While on the way to Patient 8s residence, surveyor received a message from LVN 2 that Patient 8 cancelled the visit because of a family emergency. During a telephone interview on 5/9/2024 at 10:20 a.m. with Patient 8s family member (Patient 11), Patient 11 stated Patient 8 was doing fine, never had shortness of breath at rest, and takes bronchodilator medication for years that helped relieve his respiratory symptoms like wheezing. Patient 11 further stated Patient 8 does not have terminal illness, have no family emergency and was available for a visit the day before. During an interview on 5/10/2024 at 1:15 p.m. with the acting Director of Patient Care Services (DPCS), DPCS stated he was not able to find documented evidence Patient 8 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, or had O2 saturation of 88% or less prior to hospice admission. e. During a review of Patient 10s admission record indicated a SOC date of 3/23/2024 with a terminal diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery with unspecified angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 10's Comprehensive Nursing Assessment, dated 3/23/2024, indicated Patient 10 was awake, alert, oriented x 2 (to place and person), had normal respirations, mild dyspnea with mild exertion, and required moderate assistance with ambulation, toileting and transfer, and maximum assistance with dressing and bathing. The Comprehensive Assessment also indicated Patient 10 was on NYHA IV stage of heart failure and met LCD guidelines for hospice eligibility. During a review of Patient 10s CTI, dated 3/23/2024, Physician 1 certified Patient 10 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 10 had a life expectancy of six months or less if the terminal illness runs its normal course. The narrative section did not indicate any documented and supporting evidence from the Medical Director that included laboratory test results, imaging data, and history and physical prior to hospice admission to support Patient 10s terminal illness diagnosis. During a review of Patient 10s LCD Hospice Eligibility Determination form for Heart Disease, dated 3/23/2024, indicated Patient 10 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 10 had declined surgical procedures. Section 2 was marked "yes" that Patient 10s heart disease met the criteria for NYHA Class IV level. During a review of Patient 10's clinical record indicated there was no documented evidence Patient 10 had declined surgical procedures. There was also no documented evidence Patient 10 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 5/8/2024 at 3:35 p.m. with Patient 10s family member (FM 1), FM 1 stated Patient 10 was independent, was not confined to bed or chair, walks to the store several times a week, and does not have terminal illness. During an interview on 5/10/2024 at 1:15 p.m. with the acting DPCS, DPCS stated he was not able to find documented evidence Patient 10 had had declined surgical procedures. DPCS stated there was no documented evidence Patient 10 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. f. During a review of Patient 11s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 11's Comprehensive Nursing Assessment, dated 2/21/2024, indicated Patient 11 was awake, alert, oriented x 2 (to place and person), had normal respirations, moderate dyspnea with mild exertion, and required moderate assistance with ambulation, toileting and transfer, and maximum assistance with dressing and bathing. The Comprehensive Assessment also indicated Patient 11 was on NYHA IV stage of heart failure and met LCD guidelines for hospice eligibility. The Comprehensive Nursing Assessment was not signed by a registered nurse. During a review of Patient 11s CTI, dated 2/21/2024, Physician 1 certified Patient 11 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 11 had a life expectancy of six months or less if the terminal illness runs its normal course. The narrative section did not indicate any documented and supporting evidence from the Medical Director that included laboratory test results, imaging data, and history and physical prior to hospice admission to support Patient 11s terminal illness diagnosis. During a review of Patient 11s LCD Hospice Eligibility Determination form for Heart Disease, dated 2/21/2024, indicated Patient 11 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 11 had declined surgical procedures. Section 2 was marked "yes" that Patient 11s heart disease met the criteria for NYHA Class IV level. During a review of Patient 11's clinical record indicated there was no documented evidence Patient 11 had declined surgical procedures. There was also no documented evidence Patient 11 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 5/9/2024 at 10:20 a.m. with Patient 11, Patient 11 stated no doctor or nurses told her that she had 6 months or less to live, and no one from the hospice agency explained to her that what she signed up was for hospice service, and for those patients with terminal illness. Patient 11 stated she was not confined to be or chair, was fully independent, goes to the market couple of times a week, does not have terminal illness, and requested to be removed from hospice care. During an interview on 5/10/2024 at 1:15 p.m. with the acting DPCS, DPCS stated he was not able to find documented evidence Patient 11 had had declined surgical procedures. DPCS stated there was no documented evidence Patient 11 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. g. During a review of Patient 12s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 12's Comprehensive Nursing Assessment, dated 2/21/2024, indicated Patient 12 was awake, alert, oriented x 3 (to time, place, and person), had normal respirations, moderate dyspnea with mild exertion, and required moderate assistance with ambulation, toileting, transfer, and dressing, and maximum assistance with bathing. The Comprehensive Assessment also indicated Patient 12 was on NYHA IV stage of heart failure and met LCD guidelines for hospice eligibility. During a review of Patient 12s CTI, dated 2/21/2024, Physician 1 certified Patient 12 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. The narrative section did not indicate any documented and supporting evidence from the Medical Director that included laboratory test results, imaging data, and history and physical prior to hospice admission to support Patient 12s terminal illness diagnosis. During a review of Patient 12s LCD Hospice Eligibility Determination form for Heart Disease, dated 2/21/2024, indicated Patient 12 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 12 had declined surgical procedures. Section 2 was marked "yes" that Patient 12s heart disease met the criteria for NYHA Class IV level. During a review of Patient 12's clinical record indicated there was no documented evidence Patient 12 had declined surgical procedures. There was also no documented evidence Patient 12 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a joint home visit, on 5/8/2024 at 12:30 p.m. with the licensed vocational nurse (LVN 2) at Patient 12s residence, Patient 12 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory. During an interview, Patient 12 stated nobody from the hospice agency explained to him that what he was signing up was for hospice services. Patient 12 stated he saw an ad from the agency in the grocery store offering free boxes of goods/fruits and medical devices and thinking that is what he was signing up for only. Patient 12 further stated he walked independently one hour in the morning and one hour in the afternoon to keep fit, had never had symptoms of heart disease, visits his primary physician regularly, and does not have terminal illness. During an interview on 5/10/2024 at 1:15 p.m. with the acting DPCS, DPCS stated he was not able to find documented evidence Patient 12 had had declined surgical procedures. DPCS stated there was no documented evidence Patient 12 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 5/10/2024 at 1:40 p.m. with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient 8, Patient 10, Patient 11, and Patient 12, and have not spoken and/or discussed patients medical history with them. Physician 1 stated he determined patient was eligible for hospice care by reviewing patients previous hospital records and discharge planning, and following CMS and Medicare guidelines in admitting patients in hospice service. Physician 1 further stated patients previous medical records that he reviewed prior to hospice admissions were being kept at the agencys office. During an interview, on 5/10/2024 at 2:05 p.m., with the licensed vocational nurse case manager (CM 1), a request was made from CM 1 to provide copies of Patient 8, Patient 10, Patient 11, and Patient 12 medical records and/or physician progress notes prior to patients hospice admission, but CM 1 stated the hospice agency does not have copies of the records being requested. During a review of the agencys policy and procedure titled, ";Physician Services-Medical Director", revised November 2021, indicated the hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to 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. During a review of the agencys undated policy and procedure titled ";Certification of Terminal Illness", indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. a. During a review of Patient 1s admission record indicated a start of care (SOC) date of 12/1/2024, with a terminal diagnosis of hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 12/1/23 to 2/28/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. 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 (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. On 5/8/2024, at 12:30 p.m., a home visit was conducted at Patient 1's residence with LVN1 (license vocational nurse). Patient 1 was walking in steady gait (walking with balance) without using an assistive device (any kind of tool or device that can help simplify caregiving or make the environment safer). During an interview on 5/8/2024, at 12;45 p.m., with Patient 1, Patient 1 stated she did not have an idea what hospice services was about. Patient 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). Patient 1 stated the visiting nurse (unidentified) came and visited only once during the initial (first) visit. Patient 1 stated the HA offered to provide free medical supplies such as lotions, incontinent pads (absorbent pads), and shampoo upon patient admission to their hospice service. b. During a review of Patient 2s admission record indicated a start of care (SOC) date of 1/2/2024, with a terminal diagnosis of ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 1/2/2024 to 3/31/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. 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 (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. On 5/8/2024, at 11 a.m., a home visit was conducted at Patient 2 with LVN1 (license vocational nurse). Patient 2 was observed awake, alert, oriented x 3 (to person, place and time), and ambulatory. During an interview on 5/8/2024, at 11:30 a.m., with Patient 2, Patient 2 stated the HA did not inform her about the purpose of the hospice care services. Patient 2 stated the HA would provide a nurse to visit every week to take her blood pressure and provide her with her prescribed medications. c. During a review of Patient 3s Admission Record, the Admission Record indicated a start of care (SOC) date of 1/24/2024, with a terminal diagnosis of ischemic cardiomyopathy (heart's decreased ability to pump blood properly). A review of Patient 3's Physicians Certification for Hospice Benefit, dated 1/24/2024 to 4/20/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. 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 (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a phone interview on 5/9/2024, at 11 a.m., with FM2 (family member), she stated the hospice agency did not inform Patient 3 regarding hospice services during his admission and Patient 3 was not sick and dying in six months. During a telephone interview on 5/10/2024 at 12 p.m. with the HA's Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient's 1, 2 and , 3 and have not spoken and/or discussed Patient's 1, 2, and 3's medical history with them. When asked how he determine patients were eligible for hospice care, Physician 1 stated these patients were eligible because of that referral from the hospital, the RN assessment/visit notes, as well as LCD guidelines".

Based on interview and record review, the Hospice Agency (HA) failed to ensure the medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for one of 14 sampled patients (Patient 9). This deficient practice resulted in the hospice medical director and/or physician certifying the patient who did not need hospice care and service management of terminal illness diagnosis and patient not receiving appropriate healthcare services that could affect their quality of life. --- Findings: During a review of Patient 9s admission record indicated a start of care (SOC) date of 9/20/2023 with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 9's Recertification (Re-Cert) Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), dated 3/18/2024, indicated Patient 9 was awake, alert, oriented x 3 (person, place, time), had cardiac-related pain, normal respirations, moderate dyspnea (difficult or labored breathing) with mild exertion, and requires maximum assistance with ambulation, toileting, and transfer. The Re-Cert Assessment also indicated Patient 9 was on NYHA IV (New York Heart Association Class IV - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest) stage of heart failure and met LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) guidelines for hospice eligibility. During a review of Patient 9s Certification of Terminal Illness (or CTI, Physician's certification of the patient being terminally ill to have Medicare hospice benefit), for the 3rd benefit period from 3/18/2024 to 5/16/2024, the Medical Director indicated Patient 9 was terminally ill with a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 9 had a life expectancy of six months or less if the terminal illness runs its normal course. The narrative section did not indicate any documented and supporting evidence from the Medical Director that included laboratory test results, imaging data, and history and physical prior to hospice admission to support Patient 9s terminal illness diagnosis. During a review of Patient 9s LCD Hospice Eligibility Determination form for Heart Disease, dated 3/18/2024, indicated Patient 9 was eligible per LCD guidelines. The LCD form indicated section 1 and section 2 must be met. It was marked "yes" in section 1 that Patient 1 has been ruled out as a candidate or has declined surgical procedures. Section 2 was marked "yes" that Patient 9s heart disease met the criteria for NYHA Class IV level. During a review of Patient 9's clinical record indicated there was no documented evidence Patient 9 had been ruled out as a candidate or had declined surgical procedures. There was also no documented evidence Patient 9 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest, or had an ejection fraction of less than 20. During a joint home visit, on 5/9/2024 at 1:05 p.m. with the licensed vocational nurse (LVN 1) at Patient 9s residence, Patient 9 was observed walking steadily from the door of her home to the front gate of the apartment building without the use of an assistive device, has no shortness of breath and did not complain of any chest pain. During an interview, Patient 9 stated no doctors or nurses told her that she had 6 months or less to live, that nobody explained to her that what she was signed up for hospice services, and Patient 9 thought she was signed up to get free boxes of food, glucometer (a medical device for determining the approximate concentration of glucose in the blood), and hygiene products. Patient 9 stated her own primary attending physician did not refer her to hospice care, that she had no terminal illness, not confined to bed or chair, and that she called the agency several times to discharge her from hospice service, but later found out that the agency kept on reinstating her for hospice care. During an interview on 5/10/2024 at 1:15 p.m. with the acting DPCS, stated he was not able to find documented evidence Patient 9 had been ruled out as a candidate or had declined surgical procedures. DPCS stated there was no documented evidence Patient 9 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 5/10/2024 at 1:40 p.m., with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient 9 and have not spoken and/or discussed patients medical history with Patient 9s attending physician. When asked how he determine patient's eligibility for hospice care, Physician 1 stated the patient was eligible because of his face-to-face encounter/assessment of the patient, the registered nurse assessment/visit notes, reviewing patients past medical records, and following the LCD guidelines. Physician 1 further stated patients previous medical records that he reviewed prior to hospice admissions were being kept at the agencys office. During an interview, on 5/10/2024 at 2:05 p.m., with the licensed vocational nurse case manager (CM 1), a request was made from CM 1 to provide copies of Patient 9 hospital or facilitys medical records and/or physician progress notes prior to patients hospice admission, however; CM 1 stated the hospice agency does not have copies of the records being requested. During a review of the agencys policy and procedure titled, ";Physician Services-Medical Director", revised November 2021, indicated the hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to 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. During a review of the agencys undated policy and procedure titled ";Certification of Terminal Illness", indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Clinical Records was met as follows: 1. The hospice agency failed to ensure the agency staff submitted complete clinical notes in a timely manner, and pertinent clinical records were included to reflect the care and assessment provided for four of 14 sampled patients (Patient 8, Patient 10, Patient 11, and Patient 12). (Refer to L672) 2. The hospice agency failed to ensure documentation for four of 14 sampled patients (Patient 9, Patient 10, Patient 11, and Patient 12) were accurate and authentic. For Patient 9, Patient 11 and Patient 12, the HA skilled nurse (SN) had clinical visit notes in the patients electronic health records, but the patients denied being visited by them. For Patient 10 and Patient 12, the HA failed to ensure the contents of the clinical records were protected from any modifications (making partial or minor changes) by other agency personnel who was not directly assigned to these patients. (Refer to L679) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records were safeguarded from unauthorized access by any individual or hospice staff and were maintained complete and accurate.

Based on interview and record review, the hospice agency (HA) failed to ensure the agency staff submitted complete clinical notes in a timely manner and pertinent clinical records were included to reflect the care and assessment provided for four of 14 sampled patients (Patient 8, Patient 10, Patient 11, and Patient 12). This failure resulted in patients incomplete clinical record that could lead to misinformation and non-continuity of care and services information provided to the patient. --- Findings: a. During a review of Patient 8s admission record indicated a start of care (SOC) date of 2/3/2024 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 8's Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), dated 2/3/2024, indicated Patient 8 was awake, alert, oriented x 2 (to place and person), had labored respirations (breathing), moderate dyspnea (shortness of breath) with mild exertion, and was dependent on cane or walker for ambulation. The Comprehensive Nursing Assessment was not signed by a registered nurse who conducted the assessment. During a review of Patient 8s initial Bereavement Assessment, dated 2/5/2024, indicated section 1 under ";Primary Bereaved" information was blank. The form was not signed by the hospice staff who conducted the assessment. b. During a review of Patient 10s admission record indicated a SOC date of 3/23/2024 with a terminal diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery with unspecified angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 10's Comprehensive Nursing Assessment, dated 3/23/2024, indicated Patient 10 was awake, alert, oriented x 2 (to place and person), had normal respirations, mild dyspnea with mild exertion, and required moderate assistance with ambulation, toileting and transfer, and maximum assistance with dressing and bathing. The Comprehensive Assessment was electronically signed by the previous Director of Patient Care Services (RN 1), on 5/8/2024, or more than 6 weeks after the assessment was conducted. During a review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) meeting form, dated 3/27/2024, 4/10/2024 and 4/24/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor and social worker (MSW) to visit monthly and every recertification, and hospice aide to visit two times a week. The forms were not signed by all IDG members (Medical Director, registered nurse, social worker, and the chaplain). c. During a review of Patient 11s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 11's Comprehensive Nursing Assessment, dated 2/21/2024, indicated Patient 11 was awake, alert, oriented x 2 (to place and person), had normal respirations, moderate dyspnea with mild exertion, and required moderate assistance with ambulation, toileting and transfer, and maximum assistance with dressing and bathing. The Comprehensive Nursing Assessment was not signed by a registered nurse. During a review of Patient 11s initial Bereavement Assessment, dated 2/23/2024, indicated section 1 under ";Primary Bereaved" information was blank. The form was also not signed by the staff who did the assessment. d. During a review of Patient 12s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 12's Comprehensive Nursing Assessment, dated 2/21/2024, indicated Patient 12 was awake, alert, oriented x 3 (to time, place, and person), had normal respirations, moderate dyspnea with mild exertion, and required moderate assistance with ambulation, toileting, transfer, and dressing, and maximum assistance with bathing. The Comprehensive Assessment was electronically signed by the previous Director of Patient Care Services, on 5/8/2024, or about 2 ½ months after the assessment was conducted. During a concurrent interview and record review, on 5/10/2024 at 1:15 p.m., with the acting Director of Patient Care Services (DPCS), stated comprehensive and initial bereavement assessment should be completed, documented, and signed within 5 days from the start of hospice care and service. DPCS confirmed Patient 8, Patient 10, Patient 11, and Patient 12s assessment forms were not signed by the documenting staff within 5 days from the start of care of hospice service, and therefore was not complete per the agencys policies and procedures. During a review of the agencys policy and procedure titled, ";Clinical/Service Data Collection," revised November 2021, indicated home care personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Signature authorization of clinical/service documentation will include the staff members name and credentials. All entries will reflect the date care was provided, including the month, day, and year.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure documentation for four of 14 sampled patients (Patient 9, Patient 10, Patient 11, and Patient 12) were accurate and authentic. For Patient 9, Patient 11 and Patient 12, the HA skilled nurse (SN) had clinical visit notes in the patients electronic health records, however; the patients denied being visited by the hospice staff. For Patient 10 and Patient 12, the HA failed to ensure the contents of the clinical records were protected from any modifications (making partial or minor changes) by other agency personnel who was not directly assigned to these patients. This deficient practice had the potential to result in an authorized and inaccurate patient information or assessment will be entered in the patients' clinical records which can affect their quality of care and services certified to receive the hospice care benefits. --- Findings: a. During a review of Patient 9s admission record indicated a start of care (SOC) date of 9/20/2023 with a terminal diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition when your heart doesn't pump enough blood for your body's needs). During a review of Patient 9's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 3/27/2024, indicated the frequency of visits of the registered nurse (RN) every 14 days for supervisory visit, licensed vocational nurse (LVN) to one visit per week and as needed, for ongoing assessments of all body systems, to assess monitor/assess effectiveness of current and new medication/treatment, and assess safety concerns/issues. During a review of Patient 9s SN Visit Notes calendar for the month of March 2024 and April 2024, indicated the agencys skilled nurses visited the patient at least once a week. During a joint home visit, on 5/9/2024 at 11 a.m., with a licensed vocational nurse (LVN 1) at Patient 9s residence, Patient 9 was observed awake, alert, oriented x 3 (to person, place, and time), and ambulatory without the use of an assistive device. During an interview with Patient 9, on 5/9/2024 at 11:30 a.m., Patient 9 stated she was only visited by the agencys SN once every 2 to 3 weeks for several months. When asked that per the agencys electronic health records that she was visited by the agencys SN every week per the plan of care, Patient 9 stated, ";that is not true." b. During a review of Patient 10s admission record indicated a SOC date of 3/23/2024 with a terminal diagnosis of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery with unspecified angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 10's POC/IDG form, dated 3/27/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, the spiritual counselor and social worker (MSW) to visit monthly and every recertification, hospice aide to visit two times a week, and the registered nurse to visit every 14 days for supervisory visit. During a review of Patient 10's Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), dated 3/23/2024, indicated Patient 10 was awake, alert, oriented x 2 (to place and person), had normal respirations, mild dyspnea with mild exertion, and required moderate assistance with ambulation, toileting and transfer, and maximum assistance with dressing and bathing. The Comprehensive Assessment was electronically signed by the previous Director of Patient Care Services (RN 1), on 5/8/2024, or more than 6 weeks after the assessment was conducted. c. During a review of Patient 11s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 11's POC/IDG form, dated 2/28/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, for ongoing assessments of all body systems, to assess monitor/assess effectiveness of current and new medication/treatment, and assess safety concerns/issues. During a review of Patient 11s SN Visit Notes for the month of April 2024, indicated the agencys skilled nurses visited the patient at least once a week. During a telephone interview, on 5/8/2024 at 2 p.m., with Patient 11, she stated she was not visited by the agencys SN for more than a month. d. During a review of Patient 12s admission record indicated a SOC date of 2/21/2024 with a terminal diagnosis of hypertensive heart disease with heart failure. During a review of Patient 12's POC/IDG form, dated 2/21/2024, indicated the frequency of visits of licensed vocational nurse to one visit per week and as needed, MSW and the chaplain to perform an initial assessment within 5 days of admissions, the hospice aide to visit 2 times a week, and the registered nurse to visit every 14 days for supervisory visit. During a review of Patient 12's Comprehensive Nursing Assessment, dated 2/21/2024, indicated Patient 12 was awake, alert, oriented x 3 (to time, place, and person), had normal respirations, moderate dyspnea with mild exertion, and required moderate assistance with ambulation, toileting, transfer, and dressing, and maximum assistance with bathing. The Comprehensive Assessment was electronically signed by the previous Director of Patient Care Services, on 5/8/2024, or about 2 ½ months after the assessment was conducted. During a review of Patient 12s SN Visit Notes for the month of April 2024 and May 2024, indicated the agencys skilled nurses visited the patient at least once a week. During a joint home visit, on 5/8/2024 at 12:30 p.m., with a licensed vocational nurse (LVN 2) at Patient 12s residence, Patient 12 was observed awake, alert, oriented x 3, and ambulatory without the use of an assistive device. During an interview with Patient 12, on 5/8/2024 at 12:55 p.m., Patient 12 stated he was not visited by the agencys SN for about a month. During a concurrent interview and record review, on 5/10/2024 at 12:50 p.m., with the licensed vocational nurse case manager (CM 1), CM 1 stated per the agencys clinical records. Patient 9, Patient 11 and Patient 12 had SN clinical visit notes once a week submitted by the assigned SN. A request was made from CM 1 to provide SN route sheets (a form signed by the patient certifying the time work by the agency nurse) for Patient 9, 11, and 12 but the agency was unable to provide any route sheets for Patient 9, 11 and 12 before the survey team exited the agency. During a telephone interview with RN 1, on 5/10/2024 at 2:35 p.m., when asked if he signed and completed Patient 10 and Patient 12s comprehensive nursing assessment on 5/8/2024, RN 1 stated he did not. RN 1 stated he resigned from the hospice agency effective date 4/30/2024 and does not have access anymore to the agencys electronic patient records. RN 1 stated someone from the hospice agency used his name, title, and previous access code to modify patient electronic health records. During an interview on 5/10/2024 at 2:45 p.m. with the acting Director of Patient Care Services (DPCS), DPCS acknowledged the findings and stated patient care visit should be provided to patients in accordance with the plan of care. During a review of the agencys policy and procedure titled, ";Clinical/Service Data Collection," revised November 2021, indicated home care personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Signature authorization of clinical/service documentation will include the staff members name and credentials. All entries will reflect the date care was provided, including the month, day, and year. Personnel authorized to use a computer to authenticate documentation will sign a computer confidentiality statement, verifying that no one else will be allowed to use their computer password. Each staff member will be responsible for the security of his/her computer password.

Upon patient record review, 1 of 1applicable (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient #4 The 7/8/21 Aide assignment sheet did not have a frequency for the following tasks: shower, hygiene/grooming, ambulation assist, light housekeeping.