Every finding on record at Angel Heart Hospice and Palliative Care

Based on interview the agency failed to ensure surveyors had access to complete and/or comprehensive medical records. The surveyors were not able to evaluate the initial and comprehensive assessments for 9 of 12 identified beneficiaries. This failure resulted in immediate jeopardy in which the agency had caused or had the likelihood to result in systematic failures to provide and update patient-specific initial and comprehensive assessments that accurately reflected the patient's current health status which included information to establish and monitor plans of care that met the patient's needs for hospice care and services. (Refer to L521); failed to ensure the hospice registered nurse completed an initial assessment within 48 hours after the election of hospice care for 9 of 12 patients,(Refer to L522); failed to ensure the chaplain completed the initial comprehensive spiritual assessment to assess the patient's spiritual status and needs within 5 days of admission to hospice services and failed to ensure an initial comprehensive psychosocial assessment was completed to assess the patient's psychosocial status and needs within 5 days of admission to hospice services for the current hospice beneficiaries , (Refer to L523); failed to complete a comprehensive assessment identify physical/psychosocial, emotional and spiritual needs (Refer to L524). These systemic problems resulted in the hospice agency's inability to ensure and safeguard patients rights, and the right to a confidential medical record.

Based on interview with the Administrator the agency failed to ensure surveyors had access to complete and comprehensive medical records. The surveyors were not able to evaluate the initial and comprehensive assessments for 9 of 12 patients (P) #4, #5, #6, #7, #8, #9, #10, #11 and #12 hospice beneficiaries. The finding include: 1. On December 16, 2021, at 10:15 a.m., the surveyor requested the following documents from the Administrator: current patient census, on call schedule, current patient/staff schedules and access to the complete patient medical records. The Administrator stated all medical records from March 2021, were maintained electronically but the system was down since 3:00 p.m., yesterday and she had no current medical records for the surveyor to review. At 12:35 p.m., the surveyor requested medical records for review, and the Administrator reported the system is still down. At 2:00 p.m., 3:15 p.m and at 4:00 p.m., the surveyor requested electronic access to the patients medical records. The Administrator stated the system is still down and all records and policies will be available once the system comes back up on tomorrow. 2. On December 17, 2021, at 9:10 a.m., the surveyor requested access to patient medical records. The Administrator reported the system was down and only she had access to the records and she would print medical records for review. The surveyor requested printed medical records for all 12 patients at 9:30 a.m. At 10:30 a.m., the Administrator provided 3 printed records. The Adminstrator reported the printer was very slow and she was using a lot of paper for printing. At 2:00 p.m., this surveyor requested electronic access to medical records. The Administrator stated the patient records would be sent to the surveyors. At 4:00 p.m., the requested electronic or paper record format were not provided to the survey team, the Administrator confirmed the surveyors did not have access to records. At 4:30 p.m, the surveyors did not have access to the medical records for the 9 remaining patients. 3. According to the face sheets provided by the Administrator on December 16, 2021,the following information was noted: Patient #4 was admitted to the hospice on 7/11/20, with a diagnosis of Alzheimer's disease. The clinical record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, with a diagnosis of Cerebrovascular disease. The clinical record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, with a diagnosis of Alzheimer's disease and dementia. The clinical record was not available for surveyors to review. After repeated requests the survey team never received requested medical records for 9 out of 12 patients. The hospice did not ensure documentation was readily accessible. This failure has the potential to result in patients physical, psychosocial, emotional and spiritual needs not being met for 9 of 12 patients receiving hospice services.

Based on interview with the Administrator the agency failed to ensure surveyors had access to complete and comprehensive medical records. Therefore, surveyors were not able to evaluate and determined if the initial assessment was completed within 48 hours after election of hospice services for 9 of 12 patients (P) #4, #5, #6, #7, #8, #9, #10, #11 and #12. The findings include : 1. On December 16, 2021, at 10:15 a.m., the surveyor requested the following documents: current patient census, on call schedule, current patient/staff schedule and access to the complete patient medical records. The Administrator stated all medical records from March 2021, were maintained electronically but the system was down since 3:00 p.m., yesterday and she had no current medical records for the surveyor to review. Again at 12:35 p.m., the surveyor requested medical record for review, and the Administrator reported the system is still down. At 2:00 p.m., 3:15 p.m and at 4:00 p.m., the surveyor requested electronic access to the patients medical records. The Administrator stated the system is still down and all records and policies will be available once the system comes back up on tomorrow. 2. On December 17, 2021, at 9:10 a.m., the surveyor requested access to patient medical records. The Administrator reported the system was down and only she had access to the records and she would print medical records for review. The surveyor requested printed medical records for all 12 patients at 9:30 a.m. At 10:30 a.m., the Administrator provided 3 printed records. The Adminstrator reported the printer was very slow and she was using a lot of paper for printing. At 2:00 p.m., this surveyor requested electronic access to medical records. The Administrator stated the patient records would be sent to the surveyors. At 4:00 p.m., the requested electronic or paper record format were not provided to the survey team, the Administrator confirmed the surveyors did not have access to records. At 4:30 p.m, the surveyors did not have access to the medical records for the 9 remaining patients. Patient #4 was admitted to the hospice on 7/11/20, with a diagnosis of Alzheimer's disease. The clinical record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, with a diagnosis of Cerebrovascular disease. The clinical record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, with a diagnosis of Alzheimer's disease and dementia. The clinical record was not available for surveyors to review. After repeated request the survey team never received requested initial assessments for 9 out of 12 patients. The hospice did not ensure documentation was readily accessible. This failure has the potential to result in patients physical, psychosocial, emotional and spiritual needs not being met for 9 of 12 patients receiving hospice services.

Based on interview with the Administrator the agency failed to ensure surveyors had access to complete comprehensive medical records. The surveyors were not able to determined if comprehensive assessments were completed within five calendar days of admission for 9 of 12 patients (P) #4, #5, #6, #7, #8, #9, #10, #11 and #12. The finding include: 1. On December 16, 2021, at 10:15 a.m., the surveyor requested the following documents current patient census, on call schedule, current patient/staff schedule and access to the complete patient medical records. The Administrator reported the current census is 12. She stated all medical records from March 2021, were maintained electronically but the system was down since 3:00 p.m., yesterday and she has no current medical records for the surveyor to review. At 12:35 p.m., the surveyor requested medical record for review, and the Administrator reported the system is still down. At 2:00 p.m., 3:15 p.m and at 4:00 p.m., the surveyor requested electronic access to the patients medical records. The Administrator stated the system is still down. The Administrator stated all records and policies will be available once the system comes back up on tomorrow. 2. On December 17, 2021, at 9:10 a.m., the Administrator was given a list of documents needed to complete the survey process which included initial comprehensive assessments. At 10:30 a.m., the Administrator was reminded the survey team did not receive the requested documents. At 12:40 p.m., the Administrator confirmed the requested records would be sent electronically via email. At 4:00 p.m., the requested electronic or paper record format were not provided to the survey team. After repeated requests, the survey team never received the comprehensive assessments for 9 out of 12 patients. The hospice did not ensure documentation was ready and accessible for review. This failure has the potential to result in patients physical, psychosocial, emotional and spiritual needs not being met for 9 of 12 patients receiving hospice services. Patient #4 was admitted to the hospice on 7/11/20, with a diagnosis of Alzheimer's disease. The clinical record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, with a diagnosis of Cerebrovascular disease. The clinical record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, with a diagnosis of Alzheimer's disease and dementia. The clinical record was not available for surveyors to review. Due to the lack of evidence it was determined the hospice failed to ensure the interdisciplinary group, in consultation with the individuals attending physicians (if any)completed the comprehensive assessment within five calendar days after the election of hospice care.

Based on lack of access to the clinical records the surveyor was not able to determined if the hospice agency completed a comprehensive assessment in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process for 9 of 12 patients (P) #4, #5, #6, #7, #8, #9, #10, #11 and #12. The finding include: 1. On December 17, 2021, at 10:30 a.m., the Administrator was reminded the survey team did not receive the requested documents which included a comprehensive assessment for the 9 remaining residents. At 12:40 p.m., the Administrator confirmed the requested records would be sent electronically. At 4:00 p.m., the electronic or paper record format were not provided to the survey team. The survey team never received the ongoing comprehensive assessments for 9 out of 12 patients. The hospice did not ensure documentation was readily accessible for review. This failure has the potential to result in patients physical, psychosocial, emotional and spiritual needs not being met. Patient #4 was admitted to the hospice on 7/11/20, with a diagnosis of Alzheimer's disease. The clinical record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, with a diagnosis of Cerebrovascular disease. The clinical record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, with a diagnosis of Alzheimer's disease and dementia. The clinical record was not available for surveyors to review. Due to the lack of evidence provided it was determined the hospice failed to ensure a comprehensive assessment was performed and included all areas of hospice care related to the palliation and management of the terminal illness for 9 of 12 current hospice beneficiaries.

Based on interview and a lack of access to the medical records it was determined the agency failed to ensure the documentation was readily accessible with full participation from the interdisciplinary group within the appropriate time for 9 of 12 patients. This failure resulted in an immediate jeopardy in which the agency had caused or had the likelihood to result in systematic failures to provide and update interdisciplinary group care planning and coordination of services. The requirements for the interdisciplinary group, care planning and coordination of services were not met for the following standards: The hospice failed to ensure the initial plan of care was developed for each patient with full participation of the interdisciplinary team members in consultation with the patient's attending physician (if any) for hospice beneficiaries; (Refer to L537); failed to ensure the plan of care included an interdisciplinary approach to ensure continuous assessment for each patient's and family's needs and implementation of the interdisciplinary plan of care for patients who were current hospice beneficiaries (Refer to L540); the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. (Refer to L543); failed to ensure each patient and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care for current hospice beneficiaries (Refer to L544). The following Condition and Standard level deficiencies were cited:

Based on lack of access to review Interdisciplinary group (IDG) meeting minutes and staff interview, it was determined the hospice failed to provide evidence of a designated interdisciplinary group which to prepare a written plan of care for 9 of 12 patients (P) #4, #5, #6, #7, #8, #9, #10, #11 and #12. The finding include: 1. On December 17, 2021, at 9:10 a.m., the Administrator was given a list of documents needed to complete the survey process which included Interdisciplinary group (IDG) meeting minutes. At 10:30 a.m., the Administrator was reminded the survey team had not received 9 of the documents. At 12:30 p.m., the Administrator confirmed the requested records would be sent electronically. At 4:00 p.m., the IDG meeting minutes were not provided to the survey team. Due to the lack of evidence it was determined the hospice failed to ensure the interdisciplinary group, in consultation with the individuals attending physicians completed a written plan of care for 9 of 12 hospice beneficiaries. Patient #4 was admitted to the hospice on 7/11/20, with a diagnosis of Alzheimer's disease. The clinical record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, with a diagnosis of Cerebrovascular disease. The clinical record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, with a diagnosis of Alzheimer's disease and dementia. The clinical record was not available for surveyors to review. At 4:00 p.m., the Administrator confirmed the surveyors did not have IDG minutes/notes.

Based on clinical record review and staff interviews, it was determined the hospice failed to show evidence of a designated Registered Nurse (RN) to provide coordination of care within the interdisciplinary group for 9 of 12 Patients (P) #4, #5, #6, #7, #8, #9, #10, #11, and #12. The finding include: 1. On December 17, 2021, at 9:10 a.m., the Administrator was given a list of documents needed to complete the survey process which included interdisciplinary group (IDG) meeting minutes. At 10:30 a.m., the Administrator was reminded the survey team did not receive the requested documents. At 12:30 p.m., the Administrator confirmed the requested records would be provided. At 4:00 p.m., the requested IDG meeting minutes were not provided to the survey team. Due to the lack of evidence it was determined the hospice failed to ensure the interdisciplinary group, in consultation with the individuals attending physicians had designated a RN to provide coordination of care within the interdisciplinary group. At 4:00 p.m., the Administrator confirmed the surveyors did not have IDG minutes to ensure an RN was designated to participate in the coordination of patient care services. Patient #4 was admitted to the hospice on 7/11/20, with a diagnosis of Alzheimer's disease. The clinical record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, with a diagnosis of Cerebrovascular disease. The clinical record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, with a diagnosis of Alzheimer's disease and dementia. The clinical record was not available for surveyors to review.

Based on the lack of clinical records for review and staff interviews, it was determined the hospice failed to ensure the Interdisciplinary group (IDG) established an individualized written plan of care specific to the patient and family's problems/needs for 9 of 12 Patients (P) #4, #5, #6, #7, #8, #9, #10, #11 and 12. The findings include: 1. On December 17, 2021, at 9:10 a.m., the Administrator was given a list of documents needed to complete the survey process to include patient plans of care. At 10:30 a.m., the Administrator was reminded the survey team did not receive the requested documents. At 12:30 p.m., the Administrator confirmed the requested records would be sent electronically. At 4:00 p.m., the plans of care were not provided for review. After repeated requests, the survey team never received the requested plans of care for 9 out of 12 patients. The hospice did not ensure documentation was ready and accessible for review. This failure has the potential to result in patients physical, psychosocial, emotional and spiritual needs not being met for 9 of 12 patients receiving hospice services. Patient #4 was admitted to the hospice on 7/11/20, with a diagnosis of Alzheimer's disease. The clinical record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, with a diagnosis of Cerebrovascular disease. The clinical record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, with a diagnosis of Alzheimer's disease and dementia. The clinical record was not available for surveyors to review.

Based on clinical record review and staff interview, it was determined the hospice failed to ensure each patient and the primary care giver(s) received education and training provided by the hospice as appropriate to their responsibilities for the care and services identified in the plan of care for 9 of 12 patients (P) #4, #5, #6, #7, #8, #9, #10, #11 and #12. The finding include: 1. On December 17, 2021, at 9:10 a.m., the Administrator was given a list of documents needed to complete the survey process to include the patient plans of care. At 10:30 a.m., the Administrator was reminded the survey team did not receive the requested documents. At 12:30 p.m., the Administrator confirmed the requested records would be sent electronically. At 4:00 p.m., the plans of care had not provided for review. After repeated requests, the survey team never received the plans of care for 9 out of 12 patients. The hospice did not ensure documentation was ready and accessible for review. This failure has the potential to result in patients physical, psychosocial, emotional and spiritual needs not being met for 9 of 12 patients receiving hospice services. Patient #4 was admitted to the hospice on 7/11/20, with a diagnosis of Alzheimer's disease. The clinical record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, with a diagnosis of Cerebrovascular disease. The clinical record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, with a diagnosis of Alzheimer's disease and dementia. The clinical record was not available for surveyors to review. Due to lack of evidence of education and training documentation it was determined the hospice agency failed to ensure each patient and the primary care giver(s) receive education and training provided by the hospice as appropriate to their responsibilities for the care and services for 9 of 12 patients currently receiving hospice services.

Based on staff interviews and observations, it was determined the hospice failed to provide the surveyors evidence of the Quality Assessment and Performance Improvement Program (QAPI). The QAPI requirements were not met for initial and comprehensive assessments for 12 of 12 Patients (P) #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, and #12. (Refer to L521, L522, L523, L524 ), the interdisciplinary group, care planning and coordination of services (Refer to, L536, L537 L540, L543, L544 ), Quality Assessment& Performance Improvement (Refer to , L560, L0574), Hospice Aide and Homemaker Services ( Refer to L607, L615, L629), Clinical Records were complete and accessible (Refer to L670 L671, L0672, L0678, L681), and Retrieval of clinical records complete and available (Refer to L685).

Based on staff interview, it was determined the hospice agency failed to provide the surveyors access to an ongoing Quality Assessment and Performance Improvement (QAPI) Program for 9 of 12 Patients (P) #4, #5, #6, #7, #8, #9, #10, #11, and #12. The finding include: On December 17, 2021, at 9:10 a.m., the Administrator was given a list of documents needed to complete the survey process which included evidence of a QAPI program and policies. At 10:30 a.m., the Administrator was reminded the surveyors had not receive the requested documentation. At 2:30 p.m., the Administrator reported the QAPI information was not available because it was at the Administrator's personal residence. Due to the hospice failure to provide evidence of polices and procedures for QAPI program it was determined the hospice did not have an effective and efficient program to monitor and evaluate the care and services provided all hospice beneficiaries. Refer to 42 CFR Part 418.54, Initial and Comprehensive Assessment of the Patients; 42 CFR Part 418.56, Interdisciplinary Group, Care Planning, and Coordination of Services; 42 CFR Part 418.58, Quality Assessment and Performance Improvement ; 42 CFR Part 418.76, Hospice Aide and Home Maker services; 42 CFR Part 418.100, Organization and Administration of Services; 42 CFR 418.102, Clinical Records; 418.104, Core services; 418.64, Licensed Professional services; 418.62, and Personnel Qualifications; 418.114.

Based on the inaccessibility of the quality assessment performance improvement (QAPI) policies and procedures and staff interviews, the Governing Body failed to ensure the QAPI identified and addressed patient safety and hospice operations for 12 of 12 patients (P) #1, #2, #3, 4, #5, #6, #7, #8, #9, #10, #11 and #12. The findings include: On December 17, 2021, at 9:10 a.m., the Administrator was given a list of documents needed to complete the survey process which included evidence of a QAPI program, policies and Governing Body minutes for the year on 2021. At 10:30 a.m., the Administrator was reminded the survey team did not receive the requested documents. At 2:00 p.m., the Administrator reported the QAPI information was not available because it was at the Administrator's personal residence. At 3:00 p.m., the Administrator provided the Governing Body minutes for the date 11/2021. That date was altered with the year 2021, written over another date. The Administrator was questioned regarding the dates and admitted the Governing Body minutes provided were from 11/2020, and did not provide Governing Body meeting minutes for 2021. The hospice failed to ensure a comprehensive quality assessment and improvement program was in place that required the ongoing evaluation of all hospice services, implementation of solutions, assessment of solutions, documentation of performance improvement projects, and the hospice's compliance with all regulatory requirements and failure of the Governing Body to meet annually as required.

Based on staff interviews the hospice failed to ensure that licensed professional services provided by health care professionals who meet appropriate qualifications (Refer to L 584); failed to ensure licensed professional services were provided directly by health care professionals who meet the appropriate qualifications. (Refer to L 585); failed to ensure licensed professionals actively participated in the coordination of all aspects of the patient's hospice care, in accordance with current professional standards and practice, including participating in ongoing interdisciplinary comprehensive assessments, developing and evaluating the plan of care, and contributing to patient and family counseling and education. and ( Refer to L 586) ; failed to ensure licensed professionals participated in the hospice's quality assessment and performance improvement program and hospice sponsored in-service training. The cumulative effects of these systemic problems resulted in the hospice's inability to demonstrate that licensed professionals met the patient's needs by providing skilled nursing services, hospice aide services and medical social services.

Based on personnel record review and staff interview it was determined the hospice failed to ensure licensed professional services were provided directly by health care professionals who meet the appropriate qualifications. Social work services must be based on the patient's psychosocial assessment and the patient's and family's needs and acceptance of these services for 12 of 12 patients (P) #1, #2, #3, 4, #5, #6, #7, #8, #9, #10, #11 and #12. The findings include: During an interview on December 16, 2021, at 2:40 p.m., the Administrator confirmed the personnel record for Social Worker BB did not include evidence of a licensed clinical Social Worker to meet the professional counseling needs of patients and family members. Review of the personnel file for Social Worker (SW) BB lacked evidence the employee was licensed as a Social Worker or professional counselor.

Based on staff interview and lack of documentation it was determined the hospice failed to ensure licensed professionals participated in the coordination of patient's care, within professional standards and practice, including ongoing interdisciplinary comprehensive assessments, care plans, and patient and family counseling and education for 9 of 12 patients (P) #4, #5, #6, #7, #8, #9, #10, #11 and #12. The findings include: Cross refer to L521 Cross refer to L544

Based on staff interview it was determined the hospice failed to ensure licensed professionals participated in the hospice's quality assessment performance improvement program and hospice sponsored in-service training. The finding include: During an interview on December 16, 2021, at 2:50 p.m., the Administrator stated all quality assessment documents are in the computer and the computer is down. The Administrator did not provide documentation of quality assessment and performance improvement and in-service training documentation.

Based on interview with the Administrator, it was determined the hospice failed to provide all core services directly by hospice employees (Refer to L588); failed to use contracted staff if needed to supplement hospice employees (Refer to L589) failed to ensure nursing care and services under the supervision of a Registered Nurse (Refer to L591); failed to ensure patients received a psychosocial assessment and medical social work services (Refer to L594); The hospice's failure to make available 24-hour nursing services were provided or supervised by a Registered Nurse (Refer to L653) for 9 of 12 Patients (P) #4, #5, #6, #7, #8, #9, #10, #11, and #12. The cumulative effects of these systemic problems resulted in the hospice's inability to adequately meet the patient's clinical physical, psychosocial, spiritual, emotional and dietary needs.

Based on staff interviews, it was determined the hospice failed to ensure the hospice was adequately staffed for the provision of core services directly by hospice employees in meeting the nursing services, medical social services and counseling needs for 9 of 12 patients (P) #4, #5, #6, #7, #8, #9, #10, #11 and #12. The findings include: On December 16, 2021, at 10:15 a.m., this surveyor requested current patient/staff schedule and patient /staff schedule for the last three months. The Administrator reported all patient/staff schedules are on the computer, but the system was down since 3:00 p.m., yesterday and she has no current patient /staff schedules for review. This surveyor inquired about the staff scheduled to work this week. The Administrator stated the Director of Nursing is on sick leave and there are two PRN (as needed) nurses available to visit patients if needed. At 12:01 p.m., this surveyor contacted nurse PRN FF via phone, who stated she is working at another location and has no knowledge of Angel Heart Hospice. The surveyor called several times to reach PRN nurse GG. At 12:45 p.m., the Administrator called nurse PRN GG and requested if the surveyor may interview the nurse using the Administrator's phone. Upon interview, nurse PRN GG stated she works for Angel Heart Hospice as a PRN nurse and is available to work "today " if needed. Nurse PRN GG stated she saw one patient "last week" however, could not remember the patient's name. While the surveyor was talking on the Administrator's phone a text came up from PRN Nurse GG asking the Administrator to send the patient information. The call was disconnected and the surveyor was not able to continue the interview. The Administrator stated currently the agency had one nurse who is the Director of Nursing, but out on sick leave. At 12:52 p.m the surveyor requested contracts for staff vendors. The Administrator reported the contracted nurses are no longer with the agency and the contract ended on 11/28/21. Due to the lack of written agreement with staffing agencies, it was determined the hospice failed to ensure a written agreement was created to address the hospice's professional management responsibilities, authorization of services, safety and provisions of services by qualified staff, and delivered arranged services for 12 of 12 hospice beneficiaries. During an interview on December 16, 2021, at 2:40 p.m., the Administrator confirmed the personnel record for Social Worker BB did not include evidence of a licensed clinical social worker or licensed professional counselor. Due to the lack of current patient/staff schedule, lack of hospice agency nurses, contracted nurses the agency failed to provide for the provision of core services to supplement hospice employee/staff including a Director of Nursing.

Based on staff interviews and the agency's failure to provide staffing schedules it was determined the agency failed to utilize contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients as circumstances warranted for 9 of 12 patients (P) #4, #5, #6, #7, #8, #9, #10, #11 and #12. The finding include: On December 16, 2021, at 10:15 a.m., this surveyor requested current patient/staff schedules and patient /staff schedules for the last three months. The Administrator reported all patient/staff schedules are on the computer, but the system had been down since 3:00 p.m., yesterday and she has no current patient/staff schedule for review. The Administrator stated the Director of Nursing (DON) is on sick leave and there are two PRN (as needed) nurses available to visit patients if needed. At 12:01 p.m., this surveyor contacted nurse PRN FF via phone who stated she is working at another location and had no knowledge of Angel Heart Hospice. The surveyor called several times to reach PRN nurse GG. At 12:45 p.m., the Administrator called nurse PRN GG and requested if the surveyor may interview the nurse using the Administrator's phone. Upon interview, nurse PRN GG stated she works for Angel Heart Hospice as a PRN nurse and is available to work "today " if needed. Nurse PRN GG stated she saw one patient "last week" however, could not remember the patient's name. While the surveyor was talking on the Administrator's phone a text came up from PRN Nurse GG asking the Administrator to send the patient information. The call was disconnected and the surveyor was not able to continue the interview. The Administrator stated currently the agency has a Director of Nursing on sick leave. The Administrator reported the contracted nurses are no longer with the agency and the contract ended on 11/28/21. Patient #4 was admitted to the hospice on 7/11/20, with a diagnosis of Alzheimer's disease. The clinical record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, with a diagnosis of Cerebrovascular disease. The clinical record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, with a diagnosis of Parkinson's disease. The clinical record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, with a diagnosis of Senile degeneration disease. The clinical record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, with a diagnosis of Alzheimer's disease and dementia. The clinical record was not available for surveyors to review. The agency failed to provide evidence that ensured the provision of core services to supplement hospice staff including a Director of Nursing and failed to enter into a written arrangement with contracted staff for the provision of core services.

Based on interviews, review personnel records, absence of patients records and nurse staffing schedules it was determined the agency failed to ensure the provision of nursing care and services by or under the supervision of a Registered Nurse. The agency failed to ensure nursing needs of the patient are met as identified in the patient's initial assessment, comprehensive assessment, and updated assessments. The agency did not have a staff of nurses or proof of services that meet the needs for 9 of 12 patients (P) #4, #5, #6, #7, #8, #9, #10, #11 and #12. The findings include: 1. On December 16, 2021, at 10:15 a.m., this surveyor requested access to patient medical records for 12 patients. The Administrator reported all medical records from March 2021, is on the computer, but the system had been down since 3:00 p. m., yesterday and she had no current medical records for review. At 10:45 a.m., the Administrator gave this surveyor a handwritten list of nurses who previously worked for Angel Heart Hospice. The handwritten list consisted of four nurses and one DON. The Administrator stated the four nurses were contracted with the hospice and the contract ended on November 28, 2021. This surveyor was not able to reach any of the contracted nurses for interview. At 12:35 p.m., the Administrator reported the system is still down and she was not able to provide the medical records. At 2:00 p.m., this surveyor requested if records could be sent electronically for review. The Administrator stated the system is still down. At 3:15 p.m., electronic access to the medical records had not been given to the surveyor. The Administrator stated the system is still down. At 4:00 p.m., the surveyor did not have access to the medical records, the Administrator stated all records will be available once the system comes back up tomorrow. The Administrator stated the Director of Nursing ( DON) is out today "getting pre-op work done for surgery next week". The DON will be back tomorrow (12/17/21). The Administrator stated the agency has two PRN (as needed) nurses but could not remember their last names or telephone numbers, since their information is located in the computer. After several hours the first names and telephone numbers for the 2 PRN nurses were given to the surveyors. 2. During a phone interview on December 16, 2021, at 11:00 a.m., P#10 stated the nurse comes and "takes my blood pressure and bathes me and makes me all clean". The name stated to the surveyor was identified in personnel records as CNA CC. During a phone interview on December 16, 2021, at 11:30 a.m, P#11 stated the nurse comes to see me and "bathes me, takes my blood pressure and temperature". The name stated to the surveyor was identified in the personnel records as CNA CC. The surveyor called several times to reach nurse PRN GG with no answer. At 12:45 p.m., the Administrator called nurse PRN GG and asked if this surveyor may interview her using the Administrator's phone. Upon interview, nurse PRN GG stated she works for Angel Heart Hospice as a PRN nurse and is available to work "today " if needed. Nurse PRN GG stated she saw one patient "last week" however, could not remember the patient's name. While the surveyor was talking on the Administrator's phone a text came up from PRN Nurse GG that asked the Administrator to send patient information. The call was disconnected and the interview was discontinued. On December 16, 2021, approximately at 1:00 p.m., caregiver for P#8 called the surveyor back and stated the nurse comes to "bathe the patient and take his blood pressure and temperature". The caregiver did not remember the name of the nurse. During a phone interview on December 16, 2021, at 1:10 p.m., this surveyor called nurse PRN FF, a female answered the phone and stated the name of a local hospital. This surveyor confirmed the number and name of the person as nurse PRN FF. This surveyor asked if she works as a nurse for Angel Heart Hospice she replied, "never heard of Angel Heart Hospice and never worked for the hospice" and disconnected the phone. The Administrator stated the PRN nurse is working at the hospital today and is not available to work for Angel Heart Hospice today. This surveyor requested the personnel file for the two PRN nurses. The Administrator was not able to provide the surveyor with personnel records for these two PRN nurses. The Administrator stated the files will be available tomorrow (December 17, 2021). The files were not available for review on December 17, 2021. 3. On December 17, 2021, at 9:00 a.m., during a phone interview, the caller stated on October 6, 2021, at 5:00 p.m., the blood pressure for the patient was 199/92, and had texted and called the Administrator several times with no response. The caller then called the case manager, the woman answered the phone stated she does not work for the agency but will help since she is a nurse. The Administrator identified that nurse as the DON, the nurse advised the caller to give the blood pressure medication (Amlodipine) to the patient. The caller gave the medication to the patient, and stated the Administrator responded at 7:30 p.m. The caller stated on 10/12/21, during the interdisciplinary team meeting the Administrator said the machine was broken and that is why the blood pressure reading was high. On December 17, 2021, at 9:10 a.m., the Administrator was given a list of documents needed to complete the survey process which included comprehensive assessments of patients. At 10:30 a.m., the Administrator was reminded the survey team had not receive the requested documents. At 12:45 p.m., the Administrator confirmed the requested records would be sent to the surveyors electronically. At 4:00 p.m., the requested electronic or paper record format were not provided to the survey team. On December 17, 2021, at 9:20 a.m., this surveyor asked the Administrator if the DON was available for interview. The Administrator stated the DON is out sick today as she is preparing for a surgical procedure and is very weak and not available. The Administrator stated a new Licensed Practical Nurse (LPN) is starting work on December 17, 2021, and will see all patients on December 17, 2021. The surveyor requested the LPN's personnel file, the Administrator was not able to provide this surveyor with the personnel file for this new LPN. This surveyor was not able to verify the LPN's credentials and if background checks were done prior to starting employment with this agency. The Administrator was not able to provide evidence that an LPN had been hired or trained. The Administrator stated an Registered Nurse (RN) will be starting work on December 21, 2021, but could not provide personnel records for this RN. During a home visit on December 17, 2021, at 11:15 a.m., for P#2, this surveyor observed 2 phone numbers in the patient's home. The first number was identified as the Patient Care Coordinator and the second number was listed as the Registered Nurse (RN) Case Manager. This surveyor called both numbers at 1:45 p.m. Upon calling the Patient Care Coordinator number, the Administrator of the agency answered the call and identified herself as the Administrator. When asked, the Administrator stated she was the Patient Care Coordinator. This surveyor also called the RN Case Manager Number, there was no answer to the call. During an office interview with scheduler DD at 2:20 pm. The scheduler stated the new LPN is starting today (12/17/21) and will see all patients. 4. According to the face sheets provided by the Administrator on December 16, 2021 the following information was noted: Patient #4 was admitted to the hospice on 7/11/20, diagnose with Alzheimer's disease. Clinical record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, diagnose with Parkinson's disease. Clinical record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, diagnose with Cerebrovascular disease. Clinical record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, diagnose with Parkinson's disease. Clinical record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, diagnose with Alzheimer's disease and dementia. Clinical record was not available for surveyors to review. Due to the agency's failure to provide access to the skilled nurse notes, aide visit notes and aide care plans, the surveyor was not able to determine the hospice ensured all patients were assessed by a Registered Nurse.

Based on the hospice agency's failure to provide access to Social Worker (SW) visit notes, this surveyor was not able to evaluate if a SW made onsite visits to the homes for 9 of 12 patients (P) #4, #5, #6, #7, #8, #9, #10, #11 and #12 who elected to receive hospice services. The findings include: On December 16, 2021, at 10:15 a.m., this surveyor requested access to patient medical records for 12 patients. The Administrator reported all medical records since March 2021, is on the computer, but the system had been down since 3:00 p. m., yesterday and she had no current medical records for review. At 12:35 p.m., the Administrator reported the system is down. At 2:00 p.m., the surveyor asked if records could be electronically sent for review. The Administrator stated the system is down. At 2:40 p.m., the Administrator confirmed the medical records are not available due to computer issues. At 3:15 p.m., the surveyor requested electronic access to medical records. The Administrator stated the system is down. At 4:00 p.m., the surveyor informed the Administrator this surveyor did not have access to the medical records, the Administrator stated all records will be available once the system comes back up tomorrow. 2. On December 17, 2021, at 9:10 a.m., the Administrator was given a list of documents needed to complete the survey process which included social service documentation. At 10:30 a.m., the Administrator was reminded the survey team did not receive the requested documents. At 12:45 p.m., the Administrator confirmed the requested records would be sent to the surveyors electronically. At 4:00 p.m., the requested electronic or paper record format were not provided to the survey team. At 4:00 p.m., the Administrator confirmed the surveyors did not have access to records. 3. According to the face sheets provided by the Administrator on December 16, 2021, the following information was noted: Patient #4 was admitted to the hospice on 7/11/20, diagnose with Alzheimer's disease. No social work record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, diagnose with Senile degeneration disease. No social work record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, diagnose with Senile degeneration disease. No social work record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, diagnose with Parkinson's disease. No social work record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, diagnose with Cerebrovascular disease. No social work record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, diagnose with Senile degeneration disease. No social work record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, diagnose with Parkinson's disease. No social work record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, diagnose with Senile degeneration disease. No social work record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, diagnose with Alzheimer's disease and dementia. No social work record was not available for surveyors to review. Due to the failure of the agency to provide social worker visit notes, this surveyor determined that social worker did not make onsite visits to the patient's home who received hospice services.

Based on the hospice agency's failure to provide the surveyors access to complete and comprehensive medical records (skilled nurse visit notes, written aide care plan and aide visit notes), for patients elected to receive hospice aide services, the surveyors were not able to evaluate the hospice aide and homemaker services provided for 12 of 12 patients. Refer to 418.76 Hospice Aide and Homemaker Services, 418.7(a) Hospice Aide Qualifications, 418.76(b) Content and duration of Hospice Aide classroom and supervised practical Training, 418.76(c) Competency Evaluation, 418.76(d)(1)Inservice Training, 418.76(g) Hospice Aide Assignments and Duties, 4.18.76(h)Supervision of Hospice Aides and 418.76(h)(2) A Registered Nurse must make an annual onsite visit to the location where a patient is receiving care in order to observe and assess each aide while he or she is performing care. This systemic failure resulted in the hospice's inability to meet the patient's hospice aide services.

Based on review of personnel files and staff interviews, it was determined that the hospice failed to ensure that a Registered Nurse completed an initial competency evaluation for two of three sampled Certified Nursing Assistants (CNA) DD and (CNA) CC. The findings include: The personnel records for CNA CC hired on 12/1/21, and CNA DD hired on 9/7/21, lacked documented evidence that a Registered Nurse had completed an initial competency evaluation of the aide's skills. During an interview on December 17, 2021, at 4:30 p.m., the Administrator confirmed the employees did not have the competency evaluation skills for 2021.

Based on the hospice agency's failure to provide this surveyor access to the skilled nurse visit notes, this surveyor was not able to evaluate if a Registered Nurse made onsite visits to the patients home every 14 days for 9 of 12 patients who elected to receive hospice aide services. Patients (P#) 4, #5, #6, #7, #8, #9, #10, #11 and #12 current hospice beneficiaries. The finding include: 1. On December 16, 2021, at 10:15 a.m., this surveyor requested access to patient medical records for 12 patients. The Administrator reported all medical records from March 2021, is on the computer, but the system had been down since 3:00 p. m., yesterday and she had no current medical records for review. At 12:35 p.m., this surveyor inquired about medical records, the Administrator reported the system is down. At 2:00 p.m., the surveyor asked if records could be electronically sent the Administrator stated the system is down. At 3:15 p.m., this surveyor requested electronic medical records access. The Administrator stated the system is down. At 4:00 p.m., the surveyor informed the Administrator this surveyor do not have access to the medical records, the Administrator stated all records will be available once the system comes back up tomorrow. 2. On December 17, 2021, at 9:10 a.m., the surveyor requested access to patient medical records. The Administrator reported the system was down and only she had access to the records and she would print medical records for review. The surveyor requested printed medical records for all 12 patients at 9:30 a.m. At 10:30 a.m., the Administrator provided 3 printed records. The Adminstrator reported the printer was very slow and she was using a lot of paper for printing. At 2:00 p.m., this surveyor requested electronic access to medical records. The Administrator stated the patient records would be sent to the surveyors. At 4:00 p.m., the requested electronic or paper record format were not provided to the survey team, the Administrator confirmed the surveyors did not have access to records. At 4:30 p.m, the surveyors did not have access to the medical records for the 9 remaining patients. Patient #4 was admitted to the hospice on 7/11/20, diagnose with Alzheimer's disease. Clinical record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, diagnose with Parkinson's disease. Clinical record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, diagnose with Cerebrovascular disease. Clinical record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, diagnose with Parkinson's disease. Clinical record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, diagnose with Alzheimer's disease and dementia. Clinical record was not available for surveyors to review. Due to the lack of evidence of skilled nurse visit notes, it was determined that a Registered Nurse did not make onsite supervisory visits to the patient's home at least every 14 days to assess the quality of care the hospice aide furnished, and if the aide's services met the patient's needs.

Based on lack of access to governing body minutes and interviews, the surveyors were not able to determine if the governing body demonstrated organizational management and administration of care and services necessary to effectively monitor and supervise the hospice staff and ensure the overall safety of care and services provided for 12 of 12 hospice beneficiaries and their caregivers. (Refer to L649) failure to provided access to medical records; (Refer to L 651 and L652) failure to assumed full responsibility, management and provision of hospice services; (Refer to L653); failed to ensure the hospice had adequate staff available 24-hour. The cumulative effects was determined to be a systemic failure which resulted in the hospice's inability to meet the patient's clinical physical, psychosocial, spiritual, emotional and dietary needs. The following Condition and Standard level deficiencies were cited:

Based on the hospice agency's failure to provide the surveyor access to the administrative and medical records the surveyor was not able to evaluate if the agency organized, managed, and administered its resources to provide hospice care and services to patients, caregivers and families, for 12 of 12 patients (P#'s) P#1, P#2, P#3 P#4, #5, #6, #7, #8, #9, #10, #11 and #12). The finding include: 1. On December 17, 2021, at 9:30 a.m., the surveyors requested access to patients' medical records. The Administrator provided three patients' records. At 12:00 p.m., the Administrator did not provide electronic access or documents for the remaining nine patients' records. At 5:20 p.m., the surveyors were not provided access to the nine patients' medical records. The Administrator said she "fired all her employees in November 2021, due to their failure to document their visits notes and gave them access to the electronic medical records for one month to enter the late entries after she fired them". Patient # 1 was admitted to the hospice on 8/21/21, diagnose with Alzheimer's disease. Patient #2 was admitted to the hospice on 5/26/20, diagnose with Alzheimer's disease. Patient #3 was admitted to the hospice on 2/16/20, diagnose with Alzheimer's disease. Patient #4 was admitted to the hospice on 7/11/20, diagnose with Alzheimer's disease. Patient #5 was admitted to the hospice on 6/18/20, diagnose with Senile degeneration disease. Patient #6 was admitted to the hospice on 8/12/20, diagnose with Senile degeneration disease. Patient #7 was admitted to the hospice on 12/11/20, diagnose with Parkinson's disease. Patient #8 was admitted to the hospice on 12/29/20, diagnose with Cerebrovascular disease. Patient #9 was admitted to the hospice on 3/24/21, diagnose with Senile degeneration disease. Patient #10 was admitted to the hospice on 5/4/21, diagnose with Parkinson's disease. Patient #11 was admitted to the hospice on 7/15/21, diagnose with Senile degeneration disease. Patient #12 was admitted to the hospice on 5/20/20, diagnose with Alzheimer's disease and dementia. Due to the lack of documented evidence, the surveyors were not able to determine if the hospice agency organized, managed, and administered its resources to provide hospice care and services to patients, caregivers, and families necessary for the palliation and management of terminal illness and related conditions for 12 of 12 patients. During the exit conference on December 17, 2021, at 5:20 p.m., the Administrator did not provide any additional documents.

Based on an interview and lack of access to administrative files the surveyors were not able to determine if the Governing Body assumed full responsibility for the management of the hospice, the provision of all hospice services, its fiscal operations and continuous quality assessment and performance improvement. The findings include: On December 17, 2021, at 3:56 p.m., review of the advisory board list of personnel included the Administrator, the medical director, two personnel with no titles that were appointed to the Governing Body. The appointed date was listed as November 21, 2020, however the date was changed to November 21, 2021. It was confirmed that the date was changed to November 21, 2021, by the Administrator. The surveyors were not provided with the copy of the current Quality Assurance Process Improvement program. Due to the lack of evidence, the surveyors were not able to determine that the governing body ensured the implementation and maintenance of an effective, ongoing, hospice wide, data- driven quality assessment and performance improvement program. During the exit conference on December 17, 2021, at 5:20 p.m., the Administrator did not provide any additional documents.

Based on interview, and the lack of access to the medical records the surveyors were not able to determine if the hospice engaged the necessary care and services in accordance to acceptable standards of practice for 9 of 12 patients (P) #4,#5,#6, #7,#8,#9,#10,#11,#12. The finding include: The agency's failed to provide surveyor access to the skilled nurse notes, social worker notes, physician notes, therapy notes and aide visit notes, the surveyor was not able to determine the hospice engaged the necessary care and services for the patients. Patient #4 was admitted to the hospice on 7/11/20, diagnose with Alzheimer's disease. Clinical record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, diagnose with Parkinson's disease. Clinical record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, diagnose with Cerebrovascular disease. Clinical record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, diagnose with Parkinson's disease. Clinical record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, diagnose with Alzheimer's disease and dementia. Clinical record was not available for surveyors to review. During the exit conference on December 17, 2021, at 5:20 p.m., the Administrator did not provide any additional documentation.

Based on staff interviews, review of the employee roster, absence of on-call schedules and human resource documentation, it was determined the governing body failed to ensure the hospice staffed for the availability of hospice services on a 24-hour basis to meet the needs of 12 of 12 patients (P) #1,#2, #3,#4,#5,#6, #7,#8,#9,#10,#11,#12. The findings include: 1. During a phone interview on December 16, 2021, at 1:10 p.m., this surveyor called nurse PRN FF, a female answered the phone that identified a local hospital. This surveyor confirmed the number and name of the person as nurse PRN FF. This surveyor asked if she works as a nurse for Angel Heart Hospice she replied, "never heard of Angel Heart Hospice and never worked for the hospice" and disconnected the phone. The Administrator stated the PRN nurse is working at the hospital today and is not available to work for Angel Heart Hospice today. This surveyor requested the personnel file for two PRN nurses, however, the Administrator was not able to provide the surveyor with personnel records for two PRN nurses. The Administrator stated the files will be available tomorrow (December 17, 2021). The files were not available for review on December 17, 2021. The Administrator stated that a new Licensed Practical Nurse (LPN) is starting work on December 17, 2021, and will see all patients on December 17, 2021. The surveyor requested the LPN's personnel file, the Administrator did not provide this surveyor with the personnel file for this new LPN. This surveyor was not able verify the LPN's credentials and if background checks were done prior to starting employment. The Administrator did not provide evidence that an LPN had been hired or trained. The Administrator stated that an Registered Nurse (RN) will be starting work on December 21, 2021, but could not provide personnel records for this RN. 2. On December 17, 2021, at 9:00 a.m., during a phone interview, the caller stated on October 6, 2021, at 5:00 p.m., the blood pressure for the patient was 199/92, and had texted and called the Administrator several times with no response. The caller then called the case manager, the woman answered the phone stated she does not work for the agency but will help since she is a nurse. The Administrator identified that nurse as the DON, the nurse advised the caller to give the blood pressure medication (Amlodipine) to the patient. The caller gave the medication to the patient, and stated the Administrator responded at 7:30 p.m. The caller stated on 10/12/21, during the interdisciplinary team meeting the Administrator said the machine was broken and that is why the blood pressure reading was high. On December 17, 2021, at 9:10 a.m., the Administrator was given a list of documents needed to complete the survey process which included comprehensive assessments of patients. At 9:20 a.m., this surveyor asked the Administrator if the DON was available for interview. The Administrator stated the DON is out sick today as she is preparing for a surgical procedure and is very weak therefore, she is not available. At 10:30 a.m., the Administrator was reminded that the survey team did not receive the requested documents. At 12:45 p.m., the Administrator confirmed the requested records would be sent to the surveyors electronically. At 4:00 p.m., the requested electronic or paper record format were not provided to the survey team. During a home visit on December 17, 2021, at 11:15 a.m., for P#2, this surveyor observed 2 phone numbers in the patient's home. The first number was identified as the Patient Care Coordinator and the second number was listed as the Registered Nurse (RN) Case Manager. This surveyor called both numbers at 1:45 p.m. Upon calling the Patient Care Coordinator number, the Administrator of the agency answered the call and identified herself as the Administrator. When asked, the Administrator stated she was the Patient Care Coordinator. This surveyor also called the RN Case Manager Number however, there was no answer to the call. During an office interview with scheduler DD at 2:20 pm. The scheduler stated the new LPN is starting today (12/17/21) and will see all patients. .

Based on the hospice agency's failure to provide the surveyors access to complete and comprehensive medical records, it was determined that the agency failed to present documentation of hospice physician's determination for initial certification of the terminal illness for 9 of 12 sampled patients (P#4, #5, #6, #7, #8, #9, #10, #11 and #12). The findings include: On December 17, 2021, at 9:30 a.m., the surveyors requested access to Angel Heart Hospice electronic medical record from Administrator. At 12:00 p.m., the Administrator said she was having issues with her computer and the printer was printing very slowly. At 2:00 p.m., the Administrator stated she could only print three patients' records. By 5:20 p.m., the surveyors were not provided access to nine patients' medical records. Patient #4 was admitted to the hospice on 7/11/20, diagnose with Alzheimer's disease. Certification record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, diagnose with Senile degeneration disease. Certification record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, diagnose with Senile degeneration disease. Certification record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, diagnose with Parkinson's disease. Certification record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, diagnose with Cerebrovascular disease. Certification record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, diagnose with Senile degeneration disease. Certification record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, diagnose with Parkinson's disease. Certification record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, diagnose with Senile degeneration disease. Certification record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, diagnose with Alzheimer's disease and dementia. Certification record was not available for surveyors to review. Due to the lack of evidence, the surveyors were not able to determine if the initial certification of the terminal illness was performed by the hospice's medical director and/or physician designee for 9 of 12 sampled patients. During the exit conference on December 17, 2021, at 5:20 p.m., the Administrator did not provide any additional certification information.

Based on the hospice agency's failure to provide the surveyors access to complete and comprehensive medical records, it was determined that the agency failed to provide documentation of a hospice physician's determination for written recertification of the terminal illness for 9 of 12 sampled patients. (P#4, #5, #6, #7, #8, #9, #10, #11 and #12). The findings include: On December 17, 2021, at 9:30 a.m., the surveyors requested access to Angel Heart Hospice electronic medical record from the Administrator. At 12:00 p.m., the Administrator said she was having issues with her computer and the printer was printing very slowly. At 2:00 p.m., the Administrator stated she could only print three patients' records. By 5:20 p.m., surveyors were not provided access to nine patients' medical records. Patient #4 was admitted to the hospice on 7/11/20, diagnose with Alzheimer's disease. Certification record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, diagnose with Senile degeneration disease. Certification record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, diagnose with Senile degeneration disease. Certification record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, diagnose with Parkinson's disease. Certification record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, diagnose with Cerebrovascular disease. Certification record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, diagnose with Senile degeneration disease. Certification record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, diagnose with Parkinson's disease. Certification record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, diagnose with Senile degeneration disease. Certification record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, diagnose with Alzheimer's disease and dementia. Certification record was not available for surveyors to review. Due to the lack of evidence, the surveyors were not able to determine if the recertification of the terminal illness was performed by the hospice's medical director and/or physician designee for 9 of 12 sampled patients. During the exit conference on December 17, 2021, at 5:20 p.m., the Administrator did not provide any additional information.

Based on interviews, the Administrator failed to ensure that surveyors had full access to complete clinical records that included past and current information including comprehensive assessment, plan of care, physician's orders and Interdisciplinary group notes . The surveyors were not able to evaluate the care and services provided for 9 of 12 sampled patients (P#4, #5, #6, #7, #8, #9, #10, #11 and #12). The findings include: The Administrator failed to provide past and current documented evidence of each patient's response to medications, symptom management, treatment and services to the patients. The Administrator failed to provide surveyors with all requested clinical records hard copy or in electronic form According to the face sheets provided by the Administrator on December 16, 2021 the following information was noted: Patient #4 was admitted to the hospice on 7/11/20, diagnose with Alzheimer's disease. Clinical record was not available for surveyors to review. Patient #5 was admitted to the hospice on 6/18/20, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #6 was admitted to the hospice on 8/12/20, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #7 was admitted to the hospice on 12/11/20, diagnose with Parkinson's disease. Clinical record was not available for surveyors to review. Patient #8 was admitted to the hospice on 12/29/20, diagnose with Cerebrovascular disease. Clinical record was not available for surveyors to review. Patient #9 was admitted to the hospice on 3/24/21, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #10 was admitted to the hospice on 5/4/21, diagnose with Parkinson's disease. Clinical record was not available for surveyors to review. Patient #11 was admitted to the hospice on 7/15/21, diagnose with Senile degeneration disease. Clinical record was not available for surveyors to review. Patient #12 was admitted to the hospice on 5/20/20, diagnose with Alzheimer's disease and dementia. Clinical record was not available for surveyors to review. Due to the lack of evidence, it was determined the hospice failed to ensure each patient record documented past and current initial plan of care, updated plans of care, initial assessment, comprehensive assessment, updated comprehensive assessments, clinical notes and signed copies of the patient's rights. During the exit conference on December 17, 2021, at 5:20 p.m., the Administrator did not provide any additional information.

Based on observation, staff interviews and review of the infection control policy manual, it was determined the hospice failed to maintain an infection control surveillance plan that documented, reported and monitored infections for staff and 12 of 12 patients (P) #1,#2, #3, 4, #5, #6, #7, #8, #9, #10, #11 and #12. The findings include: On December 16, 2021, at 10:15 a.m., this surveyor requested the infection control policies and procedures and a surveillance plan. The Administrator reported that all surveillance log including temperature logs are on the computer, but the system had been down since 3:00 p. m., yesterday. The Administrator stated the infection control related policies and procedure will be available once the system comes back up tomorrow. The surveyor inquired about visitor's screening for COVID-19, the Administrator replied all visitors and staff are screened for COVID-19 on a daily basis. Upon arrival the agency failed to monitor and screen this surveyor for COVID-19 until it was brought to the agency's attention by the surveyor. On December 17, 2021, a review of the infection control policies and procedures revealed a surveillance plan that required documentation, reporting and monitoring of infections and communicable diseases. The infection control documentation lacked evidence of screening and monitoring/temperature logs for signs and symptoms of infection. Review of the quality assurance manual revealed the lack of documented evidence regarding the review and monitoring of surveillance data. On December 17, 2021, at 1:00 p.m., the Administrator did not provide any infection control implementation and surveillance data.

Based on staff interview it was determined the hospice failed to ensure all personnel qualifications were kept current for staff members who are required to be certified or licensed (Refer to L 795); failed to ensure documented evidence that a criminal background check was obtained for staff members, (Refer to L 584) failed to ensure licensed professional services were provided directly by health care professionals who meet the appropriate qualifications, (Refer to L615) failed to ensure that a Registered Nurse completed an initial competency evaluation for hospice aides, (Refer to 589) ; failed to ensure to utilize qualified contracted staff, if necessary, to supplement hospice employees in order to meet the needs of patients under extraordinary or other non-routine circumstances. and (Refer to L 591) ; failed to ensure a system to adequately staff for the provision of core services. The cumulative effects of these findings it was determined that the hospice had systemic problems that resulted in the hospice's inability to meet the patient's physical, psychosocial, and spiritual needs.

Based on the hospice agency's failure to provide the surveyors access to personnel records, the surveyors were not able to evaluate the employee criminal background checks (CBC) for four (4) of seven (7) sampled employees. The findings include: On December 17, 2021, at 9:30 a.m., the surveyors requested access to Angel Heart Hospice employee electronic record or paper records from Administrator. At 12:00 p.m., the Administrator said she was having issues with her computer and the printer was printing very slowly. At 2:00 p.m., the Administrator stated she was unable to print employees' background check. By 5:20 p.m.,the surveyors were not provided the four employee's personnel files. 1. Registered Nurse Practitioner (RNP) AA was hired on 5/28/19, employee file lacked a criminal background checks. 2. Social Worker (SW) BB was hired on 5/1/21, employee file lacked a criminal background check. 3. Certified Nurse Aide (CNA) CC was hired on 12/1/21, employee file lacked a criminal background check. 4. Certified Nurse Aide (CNA) DD was hired on 9/7/21, employee file lacked a criminal background check. Due to the lack of evidence of criminal background checks it was determined the CBC were not done. , the surveyors were not able to evaluate the (RNP) AA, (SW) BB, (CNA) CC and (CNA) DD background checks for 4 of 7 sampled employees. During the exit conference on December 17, 2021, at 5:20 p.m., the Administrator did not provide any additional information.