Every finding on record at Angels Hospice Corporation

The hospice agency failed to ensure the Condition of Participation L 536 418.56: Interdisciplinary group, care planning, and coordination of services was in compliance as follows: Based on interview and record review, the agency failed to provide a higher level of care after identifying caregivers at a Board and Care Facility (B&C-a care home for patients who need assistance with daily activities like eating, medication management, toileting, and personal grooming) did not provide repositioning every two hours or incontinence care for one of three sample patients (Patient 1) when Patient 1 was immobile and unable to reposition herself to relieve pressure on her skin. (Refer to L 539) The cumulative effect of these systemic practices resulted in Patient 1 developing multiple wounds: a stage IV pressure ulcer (an open wound with full thickness skin loss and extensive destruction; tissue necrosis (dead tissue) and damage to muscle and bone) to the sacrum (triangular bone at the base of the spine), a deep tissue injury ( DTI-a pressure-related injury to tissues under intact skin) to left buttock, a stage II pressure ulcer (an open wound with partial thickness skin loss. The ulcer is superficial [on top] and presents clinically as an abrasion, blister, or shallow crater] to the right buttock, DTIs to bilateral [both] heels, due to these worsening wounds Patient 1 was hospitalized with wound infections, pain and required surgical debridement (the mechanical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue).

Based on interview and record review, the agency failed to provide a higher level of care after identifying caregivers at a Board and Care Facility (B&C-a care home for patients who need assistance with daily activities like eating, medication management, toileting, and personal grooming) did not provide repositioning every two hours or incontinence care for one of three sample patients (Patient 1) when Patient 1 was immobile and unable to reposition herself to relieve pressure on her skin. This failure resulted in Patient 1 developing multiple wounds: a stage IV pressure ulcer (an open wound with full thickness skin loss and extensive destruction; tissue necrosis (dead tissue) and damage to muscle and bone) to the sacrum (triangular bone at the base of the spine), a deep tissue injury ( DTI-a pressure-related injury to tissues under intact skin) to left buttock, a stage II pressure ulcer (an open wound with partial thickness skin loss. The ulcer is superficial [on top] and presents clinically as an abrasion, blister, or shallow crater] to the right buttock, DTIs to bilateral [both] heels, due to these worsening wounds Patient 1 was hospitalized with wound infections, pain and required surgical debridement (the mechanical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue). --- An unannounced visit was made to the facility on March 11, 2024, at 10:26 AM, to investigate a complaint regarding an allegation of abuse and neglect of Patient 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of October 22, 2022, with a benefit period of December 21, 2022, to March 20, 2023 (Second benefit period). Patient 1 had diagnoses that included ovarian cancer. Patient 1 was discharged to the hospital on March 2, 2023, for worsening pressure sores and pain and died at the hospital on March 14, 2023. During an interview with a Registered Nurse Compliance Officer (CO) on March 11, 2024, at 3:04 PM, the CO stated the issues with Patient 1 occurred a year ago and the Director of Patient Care Services (DPCS 1) and the Registered Nurse Case Manager (RNCM 1) involved in Patient 1s care and management were no longer employed by the agency. The CO stated she became involved in Patient 1s case on January 27, 2023 and continually monitored the care and services Patient 1 received. The CO stated the facility where Patient 1 lived was a residential Board and Care (B&C) with six to eight beds. The CO stated the staff were responsible for residential care such as assistance with Activities of Daily Living (ADLs-an individual's daily self-care activities). The CO stated the staff had 24 hour a day responsibility for the patients but there was no requirement for the staff to stay awake during the nighttime hours and the staff typically went to bed themselves once the patients were settled in. The CO stated the staff were expected to respond if a patient cried out in the night. The CO stated staff went to bed about 10 PM and then awoke around 5 AM to begin morning cares. The CO stated it was understood by the agencys staff who provided and directed Patient 1s care that Patient 1 was not being repositioned every two hours and incontinence care was not provided during this nighttime period. The CO stated the staff who provided and directed Patient 1s care knew Patient 1 was immobile and could not reposition herself. The CO stated the agency did not seek or offer a higher level of care ";because the patient was already in decline." The CO stated, "We are not trying to heal a wound during the last stages of life." A review of Patient 1s initial admission assessment dated October 22, 2022, by a Registered Nurse (RN 1), and recertification assessment dated December 16, 2022, by a Registered Nurse Case Manager (RNCM 1), indicated Patient 1s residence was the B&C Facility. Patient 1 had no wounds, and a Braden Scale (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure ulcers) assessment under ";mobility" indicated ";completely immobile" (does not make even slight changes in body or extremity position without assistance). During a review of a Skilled Nursing (SN) visit note dated February 13, 2023, by a Licensed Vocational Nurse (LVN 2), indicated, ";... Noted new DTI [deep tissue injury] on Lt [left] heel noted with localized area of persistent non-blanchable deep maroon, purple discoloration, skin intact; blanchable redness on Rt [right] heel, skin intact. New DTI on sacrococcyx [tailbone] area and left buttock with deep purple discoloration, see picture for illustration, pain noted on movement manifested by moaning and groaning. ..." During a review of a Skilled Nursing (SN) visit note dated February 15, 2023, by LVN 2, indicated, ";Integumentary – Skin: (DTI on left heel, central posterior [the back side] coccyx [tailbone], and rt buttock) DTI on left heel, central posterior. coccyx, and rt buttock – Moderate. ... She continues to have weakness and requires max assistance with ... ADLs, she is mainly bedbound. ..." During an interview with LVN 2 on March 11, 2024, at 2:41 PM, LVN 2 stated she had visited Patient 1 on February 13, 2023, and February 15, 2023. LVN 2 stated Patient 1 could not reposition herself. LVN 2 stated she did not know if the B&C repositioned Patient 1 every two hours during the nighttime hours. A review of a SN visit note dated February 20, 2023, by a Licensed Vocational Nurse (LVN 3), indicated, ";Upon arrival, [the Medical Director-MD 1] was at the site and saw the patient. ...Body assessment was done and noted an existing sacrococcyx pressure ulcer wound stage 3 [an open wound with full thickness skin loss involving damage or necrosis [death] of subcutaneous [underlying] tissue. The ulcer presents clinically as a deep crater] to left buttock and has opened today per pcg [primary caregiver] report. Wound bed with dark adherence slough [dead tissue] 75% [percent] and 25% granulating [new tissue filling wound] tissue irregular in shape, surrounding area with bruising. ...Pt continues to have weakness and requires max assistance with ... ADLs. ..." A review of a SN visit note dated February 27, 2023, by a Licensed Vocational Nurse (LVN 3), indicated, ";...Patient appears weak, pale, and confused. ...Stage 3 sacral pressure ulcer appears increasing in size from previous visits. Wound bed with full thickness tissue loss, darker yellow slough 50% adhering to wound bed with 50% granulating tissue to left buttock. Right buttock with appearance of stage II (an open wound with partial thickness skin loss. The ulcer is superficial [on top] and presents clinically as an abrasion, blister, or shallow crater] with discoloration with surrounding tissue, stage II to sacral area above the right buttocks, beefy red in color. ...patient noted constant moaning with facial grimacing during the entire wound care. ..." During an interview LVN 3 on March 11, 2024, at 3:29 PM, LVN 3 stated he had visited Patient 1 on February 20, 2023, and February 27, 2023. LVN 3 stated Patient 1 could not reposition herself. LVN 3 stated he did not know if the B&C repositioned Patient 1 every two hours during the nighttime hours. A review of a communication note dated March 2, 2023, by a Medical Social Worker (MSW 1), indicated, ";MSW [MSW 1] received a text message from son [name of Patient 1s son] at 1:40 am stating that he reached out to the office requesting IV [intravenous] hydration. Son stated [patients] pressure wounds and dehydration are not a natural cause of death. Son also stated that Fentanyl [a pain medication] and Morphine [a pain medication] are not natural causes of death. MSW [MSW 1] received another text message at 5:52 am stating that he [Patient 1s son] made the decision to revoke hospice care in order for [Patient 1] to receive emergency medical assistance. At 8:55 am MSW [MSW 1] received a text message stating Ok. I probably surprised everyone. I can't in good faith or conscience sit on the sidelines with this. I made this decision on my own." A review of a communication note dated March 20, 2023, by the CO, indicated, ";Received request from pt's [Patient 1s son] son [name of Patient 1s son] stating he wants "to speak with someone in charge" re [regarding] his mothers pressure ulcers. ... Ulcers developed [approximately] 14 days before [name of Patient 1s son] had pt [Patient 1] sent to acute care hospital for aggressive treatment that he previously stated he did not want. Pt [Patient 1] was at high risk for ulcers d/t [due to] poor nutrition/intake and pt [Patient 1] being dependent upon staff to reposition her. Her [Patient 1] home facility is a Board & Care facility where staff sleep at night when [patients] sleep. It is possible that [Patient 1] was not repositioned nor incontinence issues addressed during sleeping hours, thereby increasing potential for skin breakdown risks. However, the [patients] general status is declining which contributes significantly to the risks. ..." A review of the Acute Care Hospital (ACH) ";ED [Emergency Department] Note-Physician," dated March 2, 2023, indicated, ";Chief Complaint: Bed sores, History of Present Illness: ... Per report this is a 79-year-old lady with dementia [a group of conditions causing memory loss and impaired judgment], ovarian cancer, chronic pain on opioids [a class of pain medication], and on home oxygen who resides at a boarding care. Her son [name of son] lives several hours away. He states that patient has known chronic sacral decubiti that recently in the last couple weeks were noted to be worsening to a stage III, so a wound care nurse company was called out to provide wound care at the board-and-care where she lives. Son states the caregiver [name of caregiver] at the board and care had previously been doing an excellent job. He states that these nurses have been involved in caring for the patient for roughly 5 [five] to 7 [seven] days. Son states he received a phone call from [name of caregiver] stating that the patient was looking more uncomfortable, moaning, and that they were having difficulty controlling her pain and also expressed concern that the wound care nurse was not able to care for this wound properly. ... The son does state that initially she was on hydrocodone [a pain medication] for pain although he is not sure if this was pain from the cancer or the decubiti. ... He states when he received a call from [name of the caregiver] the caregiver who asked what he wanted to do about these care concerns, and he called 911 to have her brought into the emergency department. ... Physical Exam: ... General: Patient is on the gurney, moaning. When asked where she is in pain she states butt. Wails and cries out when touched or moved. ... Reexamination/Reevaluation: ... Patient is having pain and crying out when touched or moved but she does seem to understand and is redirectable. ... Decubitus ulcer looks fairly extensive and malodorous [foul smelling]. I feel this needs to be evaluated by a wound specialist. It could be infected or need some debridement. ..." A review of the Acute Care Hospital (ACH) physicians order dated March 2, 2023, indicated, ";Order: Admit to Inpatient per ED [Emergency Department], Reason: Wound, edema [swelling], elevated trop [troponin-a protein found in the cells of the heart muscle-elevated levels can indicate heart damage], agitation." A review of the Acute Care Hospital (ACH) physicians order dated March 3, 2023, indicated, ";Order: Turn Patient, Order Comment: Order entered secondary to turn patient every 2 [two] hour[s] documentation." A review of the Acute Care Hospital (ACH) ";Wound Care Note," dated March 2, 2023, indicated, ";... Wound care consult requested for altered skin in the sacrococcyx. On assessment, noted to have full thickness stage IV with tan non-viable [not capable of living] tissue with palpable [able to touch] bone. Malodor [foul smell] noted and undermining, periwound [around the wound] noted to be ischemic [inadequate blood supply] and denuded [stripped]. Left buttock noted to have DTPI [deep tissue pressure injury] with maroon and purple discoloration. Recommendations provided and reported to RN [Registered Nurse]. Recommended to obtain surgical consult. Dakins [Dakin solution is a strong topical antiseptic used to clean infected wounds, and ulcers] soaked gauze is recommended for infection and malodor. Ordered C200 low air loss [a mattress designed to prevent and treat pressure wounds] for support surface, continuing offloading [removing pressure] bilateral [both] heels with heel suspension boots. Continue turning and repositioning patient. ... Turn and reposition every 2 [two] hours. ..." A review of the Acute Care Hospital (ACH) Physician Progress Notes, dated March 4, 2023, indicated, ";Procedure Performed: Excisional [cutting] Debridement [removal of damaged tissue] of Buttocks Wound (involving skin, soft tissue, muscle and bone, [seven by four by three centimeters-a unit of measurement]. Pre-Procedure exam: Buttocks: [four by seven centimeters] decubitus ulcer [pressure ulcer], stage 4, fibrinous [stringy] exudative [oozing out] material and necrotic [dead or dying] appearing. Post-Procedure Exam: Description of Procedure: ... Using an 11 blade, I gently debrided any necrotic appearing and fibrinous exudative material, the ulceration involved skin, soft tissue, muscle and went to sacrum [triangular bone at the base of the spine]. The wound measured [four by three by seven centimeters]. I was able to debride some of the wound, however fibrinous exudative material and necrosis was extensive. ..." A review of the Acute Care Hospital (ACH) physicians order dated March 4, 2023, indicated, ";levofloxacin (Levaquin) [an antibiotic] 250 mg [milligrams-a unit of measurement] = [equals] 50 ml [milliliters-a unit of measurement], IV Soln [intravenous solution], IV Piggback, Q24H [every 24 hours], Indication: Skin/Soft Tissue infection, ..." A review of the Acute Care Hospital (ACH) ";Notification of Death," dated March 14, 2023, indicated, ";Date/Time of Death: 03/14/2023 [March 14, 2023] 01:20 PDT [AM-Pacific Daylight Time]." A review of the Acute Care Hospital (ACH) ";Discharge Summary," dated March 31, 2023, indicated, ";Patient is a 79-year-old lady with dementia, ovarian cancer, chronic pain on opioids, and on home oxygen was sent from boarding care due to worsening chronic sacral decubiti reported by HH [home health] nurse. Apparently pts son [name of patients son] lives several hours away received a call from her caregivers about patients wound getting worse and being uncomfortable so 911 was called. ... general surgeon consult requested and pt underwent bedside debridement. ... Patients son declined feeding tube as patient was not eating and after much discussion with the son, he requested comfort care and was started on morphine [a pain medication] and referred to inpatient hospice. Patient was discharged from hospital and admitted to inpatient hospice care under [name of hospice agency] and shortly expired. ...Final Dx [diagnoses]: Cardiopulmonary arrest [the heart stops beating], Seizure breakthrough, Worsening sacral decubitus ulcer s/p [status post] bedside debridement, ..." During an interview with the Medical Director (MD 1), Administrator (Admin), Director of Patient Care Services (DPCS 2) and the Compliance Officer (CO) on March 20, 2024, at 12:15 PM, MD 1 stated he visited Patient 1 on February 20, 2023. MD 1 stated Patient 1 was so weak he had to assist her to turn to assess her sacral wound. MD 1 stated he did not ask the staff if they were repositioning Patient 1 every two hours throughout the day and night. MD 1 stated he did not know the B&C did not reposition or provide incontinence care throughout the nighttime hours. MD 1 stated prolonged pressure will cause skin breakdown and prolonged pressure on an ulcer will cause the ulcer to worsen. MD 1 stated Patient 1 was at high risk for skin breakdown due to her diagnoses, but it was not unavoidable if proper care was given. MD 1 stated the Registered Nurse Case Manager (RNCM 1) should have discussed the repositioning issue in the Interdisciplinary Group (IDG) meetings so it could have been addressed early before the skin breakdown occurred but had not. MD 1 stated continuous care (continuous home care is meant to include predominately nursing care, covered for at least 8 hours, and up to 24 hours in a 24-hour period, beginning and ending at midnight) could have been initiated so the hospice clinical staff could reposition Patient 1 every two hours and provide incontinence care. MD 1 stated this way the Medical Social Worker (MSW 1) could have secured General Inpatient (GIP) services (General inpatient care (GIP) is available to all hospice beneficiaries who are in need of pain control or symptom management that cannot be provided in any other setting. Skilled nursing care may be needed by a patient whose home support has broken down if this breakdown makes it no longer feasible to furnish needed care in the home setting) from one of our five contracted Skilled Nursing Facilities (SNF) and the SNF could reposition Patient 1 every two hours and provide incontinence care 24 hours a day. MD 1 stated these were services the agency could have provided to Patient 1 allowing time for MSW 1 to find a facility with a higher level of care for Patient 1 to live. MD 1 stated the agency did not make these services available to Patient 1. A review of the agencys policy and procedure titled, ";Interdisciplinary Group Coordination of Care," dated April 2020, indicated, ";Policy: [name of agency] will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated hospice care to patients and family/caregivers. It will be the responsibility of the Clinical Supervisor/Nursing Supervisor to assign a Case Manager who is a registered nurse (RN). The Case Manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge. The type and scope of services provided by the interdisciplinary group will be based upon the comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The exact combination of services and level of care will be unique to each patient and family/caregiver unit, and it will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice. The interdisciplinary group will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to it patients." A review of the agencys policy and procedure titled, ";Continuous Care Services," dated April 2020, indicated, ";Policy: Continuous care will be available to patients receiving Medicare and Medicaid hospice benefits, or as other payers allow. Continuous care level of care must be provided a minimum of eight (8) hours to 24 hours a day during short periods in which an individual patient and family/caregiver require continuous nursing care to achieve palliation, to manage acute medical symptoms, and to maintain the patient in his/her residence." A review of the agencys policy and procedure titled, ";Admission for General Inpatient Services," dated April 2020, indicated, ";Policy: General inpatient care will be provided as specified under the Medicare, Medicaid, and specific private insurance hospice benefits. Inpatient care may be recommended in other circumstances not related to the terminal illness ...General Guidelines: 1. One (1) or more of the following clinical criteria must be present in order for the patient to be considered appropriate for admission for general inpatient care. Admission decisions are made on an individual basis after evaluation by the hospice interdisciplinary group and in consultation with the patients attending physician. ...1. Symptoms fail to respond to home management, ...5. Open lesions requiring frequent professional care (decubiti, malignant ulcerations, ...severe abrasions...at least b.i.d. [twice a day] dressing changes) beyond the capability of the primary caregiver. 8. Other presenting problems will be identified and evaluated on an individual basis..."

The agency failed to ensure the Condition of Participation: L 648 418.100 Organization and administration of services was in compliance when: Based on interview, and record review, the Governing Body (GB) failed to operate and manage the agency from October 22, 2022, to March 20, 2024, when the agency failed to provide a higher level of care after identifying caregivers at a Board and Care Facility (B&C-a care home for patients who need assistance with daily activities like eating, medication management, toileting, and personal grooming) did not provide repositioning every two hours or incontinence care for one of three sample patients (Patient 1) when Patient 1 was immobile and unable to reposition herself to relieve pressure on her skin. (Refer to L 651) The cumulative effect of these systemic practices resulted in Patient 1 developing multiple wounds: a stage IV pressure ulcer (an open wound with full thickness skin loss and extensive destruction; tissue necrosis (dead tissue) and damage to muscle and bone) to the sacrum (triangular bone at the base of the spine), a deep tissue injury ( DTI-a pressure-related injury to tissues under intact skin) to left buttock, a stage II pressure ulcer (an open wound with partial thickness skin loss. The ulcer is superficial [on top] and presents clinically as an abrasion, blister, or shallow crater] to the right buttock, DTIs to bilateral [both] heels, due to these worsening wounds Patient 1 was hospitalized with wound infections, pain and required surgical debridement (the mechanical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue).

Based on interview, and record review, the Governing Body (GB) failed to operate and manage the agency from October 22, 2022, to March 20, 2024, when the agency failed to provide a higher level of care after identifying caregivers at a Board and Care Facility (B&C-a care home for patients who need assistance with daily activities like eating, medication management, toileting, and personal grooming) did not provide repositioning every two hours or incontinence care for one of three sample patients (Patient 1) when Patient 1 was immobile and unable to reposition herself to relieve pressure on her skin. This failure resulted in Patient 1 developing multiple wounds: a stage IV pressure ulcer (an open wound with full thickness skin loss and extensive destruction; tissue necrosis (dead tissue) and damage to muscle and bone) to the sacrum (triangular bone at the base of the spine), a deep tissue injury ( DTI-a pressure-related injury to tissues under intact skin) to left buttock, a stage II pressure ulcer (an open wound with partial thickness skin loss. The ulcer is superficial [on top] and presents clinically as an abrasion, blister, or shallow crater] to the right buttock, DTIs to bilateral [both] heels, due to these worsening wounds Patient 1 was hospitalized with wound infections, pain and required surgical debridement (the mechanical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue). --- An unannounced visit was made to the facility on March 11, 2024, at 10:26 AM, to investigate a complaint regarding an allegation of abuse and neglect of Patient 1. A review of Patient 1s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of October 22, 2022, with a benefit period of December 21, 2022, to March 20, 2023 (Second benefit period). Patient 1 had diagnoses that included ovarian cancer. Patient 1 was discharged to the hospital on March 2, 2023, for worsening pressure sores and pain and died at the hospital on March 14, 2023. During an interview with a Registered Nurse Compliance Officer (CO) on March 11, 2024, at 3:04 PM, the CO stated the issues with Patient 1 occurred a year ago and the Director of Patient Care Services (DPCS 1) and the Registered Nurse Case Manager (RNCM 1) involved in Patient 1s care and management were no longer employed by the agency. The CO stated she became involved in Patient 1s case on January 27, 2023 and continually monitored the care and services Patient 1 received. The CO stated the facility where Patient 1 lived was a residential Board and Care (B&C) with six to eight beds. The CO stated the staff were responsible for residential care such as assistance with Activities of Daily Living (ADLs-an individual's daily self-care activities). The CO stated the staff had 24 hour a day responsibility for the patients but there was no requirement for the staff to stay awake during the nighttime hours and the staff typically went to bed themselves once the patients were settled in. The CO stated the staff were expected to respond if a patient cried out in the night. The CO stated staff went to bed about 10 PM and then awoke around 5 AM to begin morning cares. The CO stated it was understood by the agencys staff who provided and directed Patient 1s care that Patient 1 was not being repositioned every two hours and incontinence care was not provided during this nighttime period. The CO stated the staff who provided and directed Patient 1s care knew Patient 1 was immobile and could not reposition herself. The CO stated the agency did not seek or offer a higher level of care ";because the patient was already in decline." The CO stated, "We are not trying to heal a wound during the last stages of life." A review of Patient 1s initial admission assessment dated October 22, 2022, by a Registered Nurse (RN 1), and recertification assessment dated December 16, 2022, by a Registered Nurse Case Manager (RNCM 1), indicated Patient 1s residence was the B&C Facility. Patient 1 had no wounds, and a Braden Scale (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure ulcers) assessment under ";mobility" indicated ";completely immobile" (does not make even slight changes in body or extremity position without assistance). During a review of a Skilled Nursing (SN) visit note dated February 13, 2023, by a Licensed Vocational Nurse (LVN 2), indicated, ";... Noted new DTI [deep tissue injury] on Lt [left] heel noted with localized area of persistent non-blanchable deep maroon, purple discoloration, skin intact; blanchable redness on Rt [right] heel, skin intact. New DTI on sacrococcyx [tailbone] area and left buttock with deep purple discoloration, see picture for illustration, pain noted on movement manifested by moaning and groaning. ..." During a review of a Skilled Nursing (SN) visit note dated February 15, 2023, by LVN 2, indicated, ";Integumentary – Skin: (DTI on left heel, central posterior [the back side] coccyx [tailbone], and rt buttock) DTI on left heel, central posterior. coccyx, and rt buttock – Moderate. ... She continues to have weakness and requires max assistance with ... ADLs, she is mainly bedbound. ..." During an interview with LVN 2 on March 11, 2024, at 2:41 PM, LVN 2 stated she had visited Patient 1 on February 13, 2023, and February 15, 2023. LVN 2 stated Patient 1 could not reposition herself. LVN 2 stated she did not know if the B&C repositioned Patient 1 every two hours during the nighttime hours. A review of a SN visit note dated February 20, 2023, by a Licensed Vocational Nurse (LVN 3), indicated, ";Upon arrival, [the Medical Director-MD 1] was at the site and saw the patient. ...Body assessment was done and noted an existing sacrococcyx pressure ulcer wound stage 3 [an open wound with full thickness skin loss involving damage or necrosis [death] of subcutaneous [underlying] tissue. The ulcer presents clinically as a deep crater] to left buttock and has opened today per pcg [primary caregiver] report. Wound bed with dark adherence slough [dead tissue] 75% [percent] and 25% granulating [new tissue filling wound] tissue irregular in shape, surrounding area with bruising. ...Pt continues to have weakness and requires max assistance with ... ADLs. ..." A review of a SN visit note dated February 27, 2023, by a Licensed Vocational Nurse (LVN 3), indicated, ";...Patient appears weak, pale, and confused. ...Stage 3 sacral pressure ulcer appears increasing in size from previous visits. Wound bed with full thickness tissue loss, darker yellow slough 50% adhering to wound bed with 50% granulating tissue to left buttock. Right buttock with appearance of stage II (an open wound with partial thickness skin loss. The ulcer is superficial [on top] and presents clinically as an abrasion, blister, or shallow crater] with discoloration with surrounding tissue, stage II to sacral area above the right buttocks, beefy red in color. ...patient noted constant moaning with facial grimacing during the entire wound care. ..." During an interview LVN 3 on March 11, 2024, at 3:29 PM, LVN 3 stated he had visited Patient 1 on February 20, 2023, and February 27, 2023. LVN 3 stated Patient 1 could not reposition herself. LVN 3 stated he did not know if the B&C repositioned Patient 1 every two hours during the nighttime hours. A review of a communication note dated March 2, 2023, by a Medical Social Worker (MSW 1), indicated, ";MSW [MSW 1] received a text message from son [name of Patient 1s son] at 1:40 am stating that he reached out to the office requesting IV [intravenous] hydration. Son stated [patients] pressure wounds and dehydration are not a natural cause of death. Son also stated that Fentanyl [a pain medication] and Morphine [a pain medication] are not natural causes of death. MSW [MSW 1] received another text message at 5:52 am stating that he [Patient 1s son] made the decision to revoke hospice care in order for [Patient 1] to receive emergency medical assistance. At 8:55 am MSW [MSW 1] received a text message stating Ok. I probably surprised everyone. I can't in good faith or conscience sit on the sidelines with this. I made this decision on my own." A review of a communication note dated March 20, 2023, by the CO, indicated, ";Received request from pt's [Patient 1s son] son [name of Patient 1s son] stating he wants "to speak with someone in charge" re [regarding] his mothers pressure ulcers. ... Ulcers developed [approximately] 14 days before [name of Patient 1s son] had pt [Patient 1] sent to acute care hospital for aggressive treatment that he previously stated he did not want. Pt [Patient 1] was at high risk for ulcers d/t [due to] poor nutrition/intake and pt [Patient 1] being dependent upon staff to reposition her. Her [Patient 1] home facility is a Board & Care facility where staff sleep at night when [patients] sleep. It is possible that [Patient 1] was not repositioned nor incontinence issues addressed during sleeping hours, thereby increasing potential for skin breakdown risks. However, the [patients] general status is declining which contributes significantly to the risks. ..." A review of the Acute Care Hospital (ACH) ";ED [Emergency Department] Note-Physician," dated March 2, 2023, indicated, ";Chief Complaint: Bed sores, History of Present Illness: ... Per report this is a 79-year-old lady with dementia [a group of conditions causing memory loss and impaired judgment], ovarian cancer, chronic pain on opioids [a class of pain medication], and on home oxygen who resides at a boarding care. Her son [name of son] lives several hours away. He states that patient has known chronic sacral decubiti that recently in the last couple weeks were noted to be worsening to a stage III, so a wound care nurse company was called out to provide wound care at the board-and-care where she lives. Son states the caregiver [name of caregiver] at the board and care had previously been doing an excellent job. He states that these nurses have been involved in caring for the patient for roughly 5 [five] to 7 [seven] days. Son states he received a phone call from [name of caregiver] stating that the patient was looking more uncomfortable, moaning, and that they were having difficulty controlling her pain and also expressed concern that the wound care nurse was not able to care for this wound properly. ... The son does state that initially she was on hydrocodone [a pain medication] for pain although he is not sure if this was pain from the cancer or the decubiti. ... He states when he received a call from [name of the caregiver] the caregiver who asked what he wanted to do about these care concerns, and he called 911 to have her brought into the emergency department. ... Physical Exam: ... General: Patient is on the gurney, moaning. When asked where she is in pain she states butt. Wails and cries out when touched or moved. ... Reexamination/Reevaluation: ... Patient is having pain and crying out when touched or moved but she does seem to understand and is redirectable. ... Decubitus ulcer looks fairly extensive and malodorous [foul smelling]. I feel this needs to be evaluated by a wound specialist. It could be infected or need some debridement. ..." A review of the Acute Care Hospital (ACH) physicians order dated March 2, 2023, indicated, ";Order: Admit to Inpatient per ED [Emergency Department], Reason: Wound, edema [swelling], elevated trop [troponin-a protein found in the cells of the heart muscle-elevated levels can indicate heart damage], agitation." A review of the Acute Care Hospital (ACH) physicians order dated March 3, 2023, indicated, ";Order: Turn Patient, Order Comment: Order entered secondary to turn patient every 2 [two] hour[s] documentation." A review of the Acute Care Hospital (ACH) ";Wound Care Note," dated March 2, 2023, indicated, ";... Wound care consult requested for altered skin in the sacrococcyx. On assessment, noted to have full thickness stage IV with tan non-viable [not capable of living] tissue with palpable [able to touch] bone. Malodor [foul smell] noted and undermining, periwound [around the wound] noted to be ischemic [inadequate blood supply] and denuded [stripped]. Left buttock noted to have DTPI [deep tissue pressure injury] with maroon and purple discoloration. Recommendations provided and reported to RN [Registered Nurse]. Recommended to obtain surgical consult. Dakins [Dakin solution is a strong topical antiseptic used to clean infected wounds, and ulcers] soaked gauze is recommended for infection and malodor. Ordered C200 low air loss [a mattress designed to prevent and treat pressure wounds] for support surface, continuing offloading [removing pressure] bilateral [both] heels with heel suspension boots. Continue turning and repositioning patient. ... Turn and reposition every 2 [two] hours. ..." A review of the Acute Care Hospital (ACH) Physician Progress Notes, dated March 4, 2023, indicated, ";Procedure Performed: Excisional [cutting] Debridement [removal of damaged tissue] of Buttocks Wound (involving skin, soft tissue, muscle and bone, [seven by four by three centimeters-a unit of measurement]. Pre-Procedure exam: Buttocks: [four by seven centimeters] decubitus ulcer [pressure ulcer], stage 4, fibrinous [stringy] exudative [oozing out] material and necrotic [dead or dying] appearing. Post-Procedure Exam: Description of Procedure: ... Using an 11 blade, I gently debrided any necrotic appearing and fibrinous exudative material, the ulceration involved skin, soft tissue, muscle and went to sacrum [triangular bone at the base of the spine]. The wound measured [four by three by seven centimeters]. I was able to debride some of the wound, however fibrinous exudative material and necrosis was extensive. ..." A review of the Acute Care Hospital (ACH) physicians order dated March 4, 2023, indicated, ";levofloxacin (Levaquin) [an antibiotic] 250 mg [milligrams-a unit of measurement] = [equals] 50 ml [milliliters-a unit of measurement], IV Soln [intravenous solution], IV Piggback, Q24H [every 24 hours], Indication: Skin/Soft Tissue infection, ..." A review of the Acute Care Hospital (ACH) ";Notification of Death," dated March 14, 2023, indicated, ";Date/Time of Death: 03/14/2023 [March 14, 2023] 01:20 PDT [AM-Pacific Daylight Time]." A review of the Acute Care Hospital (ACH) ";Discharge Summary," dated March 31, 2023, indicated, ";Patient is a 79-year-old lady with dementia, ovarian cancer, chronic pain on opioids, and on home oxygen was sent from boarding care due to worsening chronic sacral decubiti reported by HH [home health] nurse. Apparently pts son [name of patients son] lives several hours away received a call from her caregivers about patients wound getting worse and being uncomfortable so 911 was called. ... general surgeon consult requested and pt underwent bedside debridement. ... Patients son declined feeding tube as patient was not eating and after much discussion with the son, he requested comfort care and was started on morphine [a pain medication] and referred to inpatient hospice. Patient was discharged from hospital and admitted to inpatient hospice care under [name of hospice agency] and shortly expired. ...Final Dx [diagnoses]: Cardiopulmonary arrest [the heart stops beating], Seizure breakthrough, Worsening sacral decubitus ulcer s/p [status post] bedside debridement, ..." During an interview with the Medical Director (MD 1), Administrator (Admin), Director of Patient Care Services (DPCS 2) and the Compliance Officer (CO) on March 20, 2024, at 12:15 PM, MD 1 stated he visited Patient 1 on February 20, 2023. MD 1 stated Patient 1 was so weak he had to assist her to turn to assess her sacral wound. MD 1 stated he did not ask the staff if they were repositioning Patient 1 every two hours throughout the day and night. MD 1 stated he did not know the B&C did not reposition or provide incontinence care throughout the nighttime hours. MD 1 stated prolonged pressure will cause skin breakdown and prolonged pressure on an ulcer will cause the ulcer to worsen. MD 1 stated Patient 1 was at high risk for skin breakdown due to her diagnoses, but it was not unavoidable if proper care was given. MD 1 stated the Registered Nurse Case Manager (RNCM 1) should have discussed the repositioning issue in the Interdisciplinary Group (IDG) meetings so it could have been addressed early before the skin breakdown occurred but had not. MD 1 stated continuous care (continuous home care is meant to include predominately nursing care, covered for at least 8 hours, and up to 24 hours in a 24-hour period, beginning and ending at midnight) could have been initiated so the hospice clinical staff could reposition Patient 1 every two hours and provide incontinence care. MD 1 stated this way the Medical Social Worker (MSW 1) could have secured General Inpatient (GIP) services (General inpatient care (GIP) is available to all hospice beneficiaries who are in need of pain control or symptom management that cannot be provided in any other setting. Skilled nursing care may be needed by a patient whose home support has broken down if this breakdown makes it no longer feasible to furnish needed care in the home setting) from one of our five contracted Skilled Nursing Facilities (SNF) and the SNF could reposition Patient 1 every two hours and provide incontinence care 24 hours a day. MD 1 stated these were services the agency could have provided to Patient 1 allowing time for MSW 1 to find a facility with a higher level of care for Patient 1 to live. MD 1 stated the agency did not make these services available to Patient 1. A review of the agencys policy and procedure titled, ";Interdisciplinary Group Coordination of Care," dated April 2020, indicated, ";Policy: [name of agency] will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated hospice care to patients and family/caregivers. It will be the responsibility of the Clinical Supervisor/Nursing Supervisor to assign a Case Manager who is a registered nurse (RN). The Case Manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge. The type and scope of services provided by the interdisciplinary group will be based upon the comprehensive and ongoing assessments regarding the needs of the patient and family/caregiver and the comprehensive plan of care that defines patient and family/caregiver problems, goals, and interventions. The exact combination of services and level of care will be unique to each patient and family/caregiver unit, and it will change as the needs of the patient and family/caregiver evolve over the course of their involvement with hospice. The interdisciplinary group will maintain responsibility for the provision and coordination of care, regardless of the setting where care is provided to it patients." A review of the agencys policy and procedure titled, ";Continuous Care Services," dated April 2020, indicated, ";Policy: Continuous care will be available to patients receiving Medicare and Medicaid hospice benefits, or as other payers allow. Continuous care level of care must be provided a minimum of eight (8) hours to 24 hours a day during short periods in which an individual patient and family/caregiver require continuous nursing care to achieve palliation, to manage acute medical symptoms, and to maintain the patient in his/her residence." A review of the agencys policy and procedure titled, ";Admission for General Inpatient Services," dated April 2020, indicated, ";Policy: General inpatient care will be provided as specified under the Medicare, Medicaid, and specific private insurance hospice benefits. Inpatient care may be recommended in other circumstances not related to the terminal illness ...General Guidelines: 1. One (1) or more of the following clinical criteria must be present in order for the patient to be considered appropriate for admission for general inpatient care. Admission decisions are made on an individual basis after evaluation by the hospice interdisciplinary group and in consultation with the patients attending physician. ...1. Symptoms fail to respond to home management, ...5. Open lesions requiring frequent professional care (decubiti, malignant ulcerations, ...severe abrasions...at least b.i.d. [twice a day] dressing changes) beyond the capability of the primary caregiver. 8. Other presenting problems will be identified and evaluated on an individual basis..." During an interview with the Administrator (Admin), in the presence of the Director of Patient Care Services (DPCS 2), and a Licensed Clinical Social Worker (LCSW) on March 20, 2024, at 2:42 PM, the Admin stated she was a member of the Governing Body (GB) along with MD 1, DPCS 2, LCSW, CO and Chief Operating Officer/Owner (CEO/Owner). The Admin stated the GB assumed full legal authority and responsibility for the operation of the agency, and for the quality of care and services provided. The Admin stated the GB had not identified Patient 1s need for a higher level of care. The Admin stated the GB had not provided continuous care services or General Inpatient (GIP) services to provide a higher level of care to Patient 1. A review of the agencys policy and procedure titled, ";Governing Body," dated April 2020, indicated, ";Policy: The Governing Body will assume full legal authority and responsibility for the operation of [name of agency]. The Governing Body of [name of agency] will serve as the governing authority for the hospice program, which will function according to [name of agency] bylaws. ... Procedure: ... 4. The Governing Body will routinely evaluate to what extent the hospice has met the needs of the community for hospice care. Has provided adequate and appropriate care to patients, ..."

Based on interview and record review, the agency failed to collaborate with local, regional, State, and Federal emergency preparedness officials to cooperate in the planning efforts and maintain an integrated response during a disaster or emergency for the 2023 year reviewed, in a universe of 73 patients. This failure had the potential to place the agencys patients at risk when the agency was not prepared to work with the emergency management office during an emergency or disaster. --- A review of the agencys Emergency Preparedness Binder, undated, on August 3, 2023, was conducted. There was no documented evidence to show contact information for local, regional, State, and Federal emergency preparedness officials. There was no documented evidence to show the agency had reached out to and collaborated with local, regional, State, and Federal emergency preparedness officials. During an interview with the Administrator (Admin) and Spiritual Counselor (SC 1) on August 3, 2023, at 11:49 AM, the Admin stated she and SC 1 were responsible for the Emergency Preparedness Program (EPP). The Admin stated she had not reached out to their local Emergency Management Office. The Admin stated she had not collaborated with the local, regional, State, and Federal emergency preparedness officials and did not know who to report patients or staff they could not reach after an emergency or patients in need of evacuation. A review of the agencys policy and procedure titled, "Emergency Management Plan," dated April 2020, indicated, ";POLICY: The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations. ... Communication Plan: The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated at least every two (2) years. The plan includes the following: ... 2. Contact information for the following: A. Federal, state, tribal, regional and/or local emergency preparedness staff. ... 6. A means of informing tribal, regional, federal, state, and local emergency preparedness officials before, during and after an emergency, in an effort to maintain an integrated response during a disaster or emergency situation, on the following: A. Patients that the organization has been unable to contact to determine service needs. B. Patients in need of evacuation due to their medical or behavioral health or conditions of the home environment. 7. A means of providing information about the organization's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. ..."

Based on interview and record review the agency failed to develop a procedure and/or process to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency, for the 2023 year reviewed, in a universe of 73 patients. This failure had the potential to place the agencys patients at risk when the agency was not prepared to respond in an emergency or disaster. --- A review of the agencys ";Emergency Management," Binder, undated, was conducted. There was no documented evidence to show a process to inform state and local officials of on-duty staff and patients they were unable to contact during a disaster or emergency. There was no documented evidence to show contact information for the emergency management offices in the counties and cities were the agencys patients lived. During an interview with the Administrator (Admin) and Spiritual Counselor (SC 1) on August 3, 2023, at 12:50 PM, the Admin stated she and SC 1 were responsible for the Emergency Preparedness Program (EPP). The Admin stated she had not reached out to their local Emergency Management Office. The Admin stated she did not have a phone number for the emergency management office to report on-duty staff and patients the agency was unable to contact. A review of the agencys policy and procedure titled, "Emergency Management Plan," dated April 2020, indicated, ";POLICY: The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations. ... Communication Plan: The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated at least every two (2) years. The plan includes the following: ... 2. Contact information for the following: A. Federal, state, tribal, regional and/or local emergency preparedness staff. ... 6. A means of informing tribal, regional, federal, state, and local emergency preparedness officials before, during and after an emergency, in an effort to maintain an integrated response during a disaster or emergency situation, on the following: A. Patients that the organization has been unable to contact to determine service needs. ..."

Based on interview and record review, the agency failed to implement policies and procedures to inform emergency preparedness officials about patients in need of evacuation and the needs the patients would require during the evacuation process, for the 2023 year reviewed, in a universe of 73 patients. This failure had the potential to place the agencys patients at risk when the agency was not prepared to inform emergency management services about patients in need of evacuation and the needs the patients would require during the evacuation process. --- A review of the agencys Emergency Management," Binder, undated, on August 3, 2023, was conducted. There was no documented evidence to show contact information for the agencys local emergency management office. There was no documented evidence to show the agency had reached out to the local emergency management office to obtain contact information and directions on reporting to officials about patients in need of evacuation and the needs the patients would require during the evacuation process. During an interview with the Administrator (Admin) and Spiritual Counselor (SC 1) on August 3, 2023, at 1:05 PM, the Admin stated she and SC 1 were responsible for the Emergency Preparedness Program (EPP). The Admin stated she had not reached out to the local emergency management office and did not know the contact information or process to report to officials about patients in need of evacuation and the needs the patients would require during the evacuation process. A review of the agencys policy and procedure titled, "Emergency Management Plan," dated April 2020, indicated, ";POLICY: The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations. ... Communication Plan: The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated at least every two (2) years. The plan includes the following: ... 2. Contact information for the following: A. Federal, state, tribal, regional and/or local emergency preparedness staff. ... 6. A means of informing tribal, regional, federal, state, and local emergency preparedness officials before, during and after an emergency, in an effort to maintain an integrated response during a disaster or emergency situation, on the following: ...B. Patients in need of evacuation due to their medical or behavioral health or conditions of the home environment."

Based on interview and record review, the agency failed to develop a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency, for the 2023 year reviewed, in a universe of 73 patients. This failure had the potential to place the agencys patients at risk when the agency did not implement a back-up communication plan with Federal, State, tribal, regional, and local emergency management agencies in the event of communications failure. --- A review of the agencys Emergency Management," Binder, undated, on August 3, 2023, was conducted. There was no documented evidence to show contact information for the agencys local emergency management office. There was no documented evidence to show the agency had reached out to the local emergency management office to obtain information on a back-up communication plan in the event of communications (phone service, including cellular phone and Internet) failure during a disaster or emergency. During an interview with the Administrator (Admin) and Spiritual Counselor (SC 1) on August 3, 2023, at 1:15 PM, the Admin stated she and SC 1 were responsible for the Emergency Preparedness Program (EPP). The Admin stated she had not reached out to the local emergency management office and did not know a back-up communication plan with the emergency management office in the event of a communications failure. A review of the agencys policy and procedure titled, "Emergency Management Plan," dated April 2020, indicated, ";POLICY: The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations. ... Communication Plan: The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated at least every two (2) years. The plan includes the following: ... 2. Contact information for the following: A. Federal, state, tribal, regional and/or local emergency preparedness staff. 3. Primary and alternate means for communicating with the staff, federal, State, tribal, regional and local emergency management agencies."

Based on interview and record review, the agency failed to implement a policy and procedure to provide information about the agencys occupancy, needs and staff available to help during an emergency or disaster to the authority having jurisdiction, for the 2023 year reviewed, in a universe of 73 patients. This failure had the potential to cause the agency not to receive help and support from the authority having jurisdiction or provide staff available to help to the authority having jurisdiction. --- A review of the agencys Emergency Management," Binder, undated, on August 3, 2023, was conducted. There was no documented evidence to show contact information for the agencys local emergency management office. There was no documented evidence to show the agency had reached out to the local emergency management office to obtain contact information and directions on reporting the agencys occupancy, needs and staff available to help during an emergency or disaster. During an interview with the Administrator (Admin) and Spiritual Counselor (SC 1) on August 3, 2023, at 12:50 PM, the Admin stated she and SC 1 were responsible for the Emergency Preparedness Program (EPP). The Admin stated she had not reached out to their local Emergency Management Office. The Admin stated she did not have a phone number for the emergency management office to report the agencys occupancy, needs and staff available to help during an emergency or disaster. A review of the agencys policy and procedure titled, "Emergency Management Plan," dated April 2020, indicated, ";POLICY: The organization will comply with all applicable, Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations. ... Communication Plan: The organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated at least every two (2) years. The plan includes the following: ... 2. Contact information for the following: A. Federal, state, tribal, regional and/or local emergency preparedness staff. ... 6. A means of informing tribal, regional, federal, state, and local emergency preparedness officials before, during and after an emergency, in an effort to maintain an integrated response during a disaster or emergency situation, on the following: ... 7. A means of providing information about the organization's needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. ..."

The agency failed to ensure that the Condition of Participation: L 664 418.102 Medical director was in compliance as follows: Based on interview, and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for 16 of 19 sampled patients (Patients 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, 19) when: 1. For Patients 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, and 19, the Medical Director used a standard language for all the patients and did not compose a physician's summary which reflected the patients' individual clinical circumstances and supported a prognosis of six months or less of life expectancy. (Refer to L 667) 2. For Patients 4 and 7, the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. (Refer to L 667) 3. For Patients 5, 15, and 17, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. (Refer to L 667) The cumulative effect of these systemic practices resulted in the potential to cause Patients 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, and 19 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon.

Based on interview, and record review, the agency failed to ensure the Medical Director (MD) certified the patients' terminal illnesses (Certification of Terminal Illness-CTI-a prognosis of six months or less life expectancy if the disease runs its normal course) before the agency submitted a claim for payment, for 16 of 19 sampled patients (Patients 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, 19) when: 1. For Patients 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, and 19, the Medical Director used a standard language for all the patients and did not compose a physician's summary which reflected the patients' individual clinical circumstances and supported a prognosis of six months or less of life expectancy. 2. For Patients 4 and 7, the CTI did not contain a face-to-face encounter (an in-person non-certifying physicians or nurse practitioners clinical assessment of the patient) conducted by a non-certifying physician or nurse practitioner. 3. For Patients 5, 15, and 17, the CTI for the first 90-day benefit period (hospice services are provided in two 90-day benefit periods and an unlimited number of 60-day benefit periods) was not signed by two physicians. This failure had the potential to cause Patients 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18, 19 to give up curative treatments and opt for palliative (to make the effects of a disease less severe) care, too soon, due to not being properly evaluated as terminally ill. --- 1a. A review of Patient 2s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 3, 2023, with a benefit period of June 3, 2023, to August 31, 2023 (First 90-day benefit period). Patient 2 had diagnoses that included hypertensive heart disease (heart disease caused by high blood pressure). A review of Patient 2s ";Physicians Certification for Hospice Benefit," dated June 3, 2023, to August 31, 2023, by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG [Interdisciplinary Group-a group of health care professionals who work in a coordinated fashion toward a common goal for a patient] discussion for admission done and based on the LCD [Local Coverage Determination-guidelines to help providers determine when patients are appropriate for the Medicare Hospice benefit] guidelines, patient is appropriate for hospice." 1b. A review of Patient 3s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 27, 2023, with a benefit period of April 27, 2023, to July 25, 2023 (First 90-day benefit period). Patient 3 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 3s ";Physicians Certification for Hospice Benefit," dated April 27, 2023, to July 25, 2023, by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG discussion for admission done and based on the LCD guidelines, patient is appropriate for hospice." 1c. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 20, 2023, with a benefit period of April 20, 2023, to June 18, 2023 (Fourth benefit period) and June 19, 2023 to August 17, 2023 (Fifth benefit period). Patient 4 had diagnoses that included diastolic heart failure (the heart does not relax between beats leading to insufficient filling and blood flow). A review of Patient 4s ";Physicians Certification for Hospice Benefit," dated April 20, 2023, to June 18, 2023 (Fourth benefit period), by a Medical Director (MD), indicated, ";Certifying Physician Summary: Patient remains appropriate for recertification based on the LCD guidelines and IDG discussion." A review of Patient 4s ";Physicians Certification for Hospice Benefit," dated June 19, 2023 to August 17, 2023 (Fifth benefit period), by a Medical Director (MD), indicated, ";Certifying Physician Summary: Patient remains appropriate for recertification based on the LCD guidelines and IDG discussion." 1d. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 22, 2023, with a benefit period of June 22, 2023, to September 19, 2023 (First 90-day benefit period). Patient 5 had diagnoses that included heart failure (the heart cannot pump blood effectively to meet the bodys needs). A review of Patient 5s ";Physicians Certification for Hospice Benefit," dated June 22, 2023, to September 19, 2023, by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG discussion for admission done and based on the LCD guidelines, patient is appropriate for hospice." 1e. A review of Patient 6s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 20, 2023, with a benefit period of June 20, 2023, to September 17, 2023 (First 90-day benefit period). Patient 6 had diagnoses that included heart failure (the heart cannot pump blood effectively to meet the bodys needs). A review of Patient 6s ";Physicians Certification for Hospice Benefit," dated June 20, 2023, to September 17, 2023, by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG discussion for admission done and based on the LCD guidelines, patient is appropriate for hospice." 1f. A review of Patient 7s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 15, 2023, with a benefit period of June 15, 2023, to August 13, 2023 (Third benefit period). Patient 7 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 7s ";Physicians Certification for Hospice Benefit," dated June 15, 2023, to August 13, 2023 (Third benefit period), by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG discussion for admission done and based on the LCD guidelines, patient is appropriate for hospice." 1g. A review of Patient 8s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 6, 2023, with a benefit period of June 6, 2023, to September 3, 2023 (First 90-day benefit period). Patient 8 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 8s ";Physicians Certification for Hospice Benefit," dated June 6, 2023, to September 3, 2023, by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG discussion for admission done and based on the LCD guidelines, patient is appropriate for hospice." 1h. A review of Patient 9s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 5, 2023, with a benefit period of June 5, 2023, to September 2, 2023 (First 90-day benefit period). Patient 9 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 9s ";Physicians Certification for Hospice Benefit," dated June 5, 2023, to September 2, 2023, by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG discussion for admission done and based on the LCD guidelines, patient is appropriate for hospice." 1i. A review of Patient 10s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 3, 2023, with a benefit period of June 3, 2023, to August 1, 2023 (Seventh benefit period). Patient 10 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 10s ";Physicians Certification for Hospice Benefit," dated June 3, 2023, to August 1, 2023 (Seventh benefit period), by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG discussion for readmission done and based on the LCD guidelines, patient is appropriate for hospice." 1j. A review of Patient 11s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 4, 2023, with a benefit period of July 4, 2023, to October 1, 2023 (First 90-day benefit period). Patient 11 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 11s ";Physicians Certification for Hospice Benefit," dated July 4, 2023, to October 1, 2023, by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG discussion done for admission and based on the LCD guidelines, patient is appropriate for hospice." 1k. A review of Patient 12s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 10, 2023, with a benefit period of July 10, 2023, to October 7, 2023 (First 90-day benefit period). Patient 12 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 12s ";Physicians Certification for Hospice Benefit," dated July 10, 2023, to October 7, 2023, by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG discussion for admission done and based on the LCD guidelines, patient is appropriate for hospice." 1l. A review of Patient 15s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 27, 2023, with a benefit period of April 27, 2023, to July 25, 2023 (First 90-day benefit period). Patient 15 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 15s ";Physicians Certification for Hospice Benefit," dated April 27, 2023, to July 25, 2023 by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG discussion for admission done and based on the LCD guidelines, patient is appropriate for hospice." 1m. A review of Patient 16s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of July 31, 2022, with a benefit period of May 27, 2023, to July 25, 2023 (Ninth benefit period). Patient 16 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 16s ";Physicians Certification for Hospice Benefit," dated May 27, 2023, to July 25, 2023 by a Medical Director (MD), indicated, ";Certifying Physician Summary: Remains appropriate for recertification based on the LCD guidelines and IDG discussion." 1n. A review of Patient 17s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 12, 2023, with a benefit period of April 12, 2023, to July 10, 2023 (First 90-day benefit period). Patient 17 had diagnoses that included Parkinsons disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). A review of Patient 17s ";Physicians Certification for Hospice Benefit," dated April 12, 2023, to July 10, 2023 by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG discussion for admission done and based on the LCD guidelines, patient is appropriate for hospice." 1o. A review of Patient 18s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of February 15, 2023, with a benefit period of February 15, 2023, to May 15, 2023 (First 90-day benefit period). Patient 18 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 18s ";Physicians Certification for Hospice Benefit," dated February 15, 2023, to May 15, 2023 by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG discussion for admission done and based on the LCD guidelines, patient is appropriate for hospice." 1p. A review of Patient 19s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of March 7, 2023, with a benefit period of March 7, 2023, to June 4, 2023 (First 90-day benefit period). Patient 19 had diagnoses that included stroke (blood flow to the brain is blocked or there is sudden bleeding in the brain). A review of Patient 19s ";Physicians Certification for Hospice Benefit," dated February 15, 2023, to May 15, 2023 by a Medical Director (MD), indicated, ";Certifying Physician Summary: IDG discussion for admission done and based on the LCD guidelines, patient is appropriate for hospice." During a concurrent interview and record review with the Medical Director (MD), Administrator (Admin), Director of Patient Care Services (DPCS), Compliance Officer (CO) and Administrator Designee (AD) on August 3, 2023, from 10:39 AM to 11:21 AM, Patients 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 16, 17, 18 and 19s Physicians Certifications for Hospice Benefit, were reviewed. The MD stated he used a standard language for all the patients and did not compose a physician's summary which reflected the patients' individual clinical circumstances that supported a prognosis of six months or less of life expectancy. The MD stated he was aware of the requirement for the physicians summary however he did not have the time to compose a summary to reflect the individual clinical circumstances that supported a prognosis of six months or less of life expectancy. 2a. A review of Patient 4s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 20, 2023, with a benefit period of April 20, 2023, to June 18, 2023 (Fourth benefit period). Patient 4 had diagnoses that included diastolic heart failure (the heart does not relax between beats leading to insufficient filling and blood flow). A review of Patient 4s ";Physicians Certification for Hospice Benefit," dated April 20, 2023, to June 18, 2023 (Fourth benefit period), indicated a signature by the Medical Director (MD). A review of Patient 4s face-to-face encounter for the fourth benefit period dated April 20, 2023, to June 18, 2023, indicated the face-to-face encounter had been conducted by the MD. 2b. A review of Patient 7s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 15, 2023, with a benefit period of June 15, 2023, to August 13, 2023 (Third benefit period). Patient 7 had diagnoses that included senile degeneration of brain (the mental deterioration-loss of intellectual ability-that is associated with or the characteristics of old age). A review of Patient 7s ";Physicians Certification for Hospice Benefit," dated June 15, 2023, to August 13, 2023 (Third benefit period), indicated a signature by the Medical Director (MD). A review of Patient 7s face-to-face encounter for the third benefit period dated June 15, 2023, to August 13, 2023, indicated the face-to-face encounter had been conducted by the MD. During a concurrent interview and record review with the Medical Director (MD), Administrator (Admin), Director of Patient Care Services (DPCS), Compliance Officer (CO) and Administrator Designee (AD) on August 3, 2023, at 11:05 AM, Patients 4, and 7s Physicians Certifications for Hospice Benefit and face to face encounters were reviewed. The MD stated he had signed Patient 4 and 7s ";Physicians Certification for Hospice Benefit," dated April 20, 2023, to June 18, 2023, and June 15, 2023, to August 13, 2023, respectively. The MD stated he had conducted Patients 4 and 7s face to face encounters, dated April 20, 2023, to June 18, 2023, and June 15, 2023, to August 13, 2023, respectively. The MD stated he did not know the certifying doctor could not conduct the face-to-face encounter. The Admin, DPCS, CO and AD stated they did not know the certifying doctor could not conduct the face-to-face encounter. 3a. A review of Patient 5s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of June 22, 2023, with a benefit period of June 22, 2023, to September 19, 2023 (First 90-day benefit period). Patient 5 had diagnoses that included heart failure (the heart cannot pump blood effectively to meet the bodys needs). A review of Patient 5s physicians order (by Attending Physician-AP 1) dated June 21, 2023, indicated a hospice referral to the agency. A review of Patient 5s ";Physicians Certification for Hospice Benefit," dated June 22, 2023, to September 19, 2023, indicated Patient 5 was in his first 90-day benefit period. Patient 5s ";Physicians Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP 1) should sign. There was no documented evidence to show AP 1 had signed Patient 5s ";Physicians Certification for Hospice Benefit." A review of Patient 5s claims for payment, indicated a claim for payment was submitted on July 3, 2023. During a concurrent interview and record review with the Medical Director (MD), Administrator (Admin), Director of Patient Care Services (DPCS), Compliance Officer (CO) and Administrator Designee (AD) on August 3, 2023, at 11:02 AM, Patient 5s ";Physicians Certification for Hospice Benefit," dated June 22, 2023, to September 19, 2023, was reviewed. The MD, Admin, DPCS, CO and AD verified AP 1 had not signed Patient 5s ";Physicians Certification for Hospice Benefit," and the agency had submitted a claim for payment. 3b. A review of Patient 15s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 27, 2023, with a benefit period of April 27, 2023, to July 25, 2023 (First 90-day benefit period). Patient 15 had diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 15s physicians order (by Attending Physician-AP 2) dated April 27, 2023, indicated a hospice referral to the agency. A review of Patient 15s ";Physicians Certification for Hospice Benefit," dated April 27, 2023, to July 25, 2023 indicated Patient 15 was in her first 90-day benefit period. Patient 15s ";Physicians Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP 2) should sign. Patient 15s ";Physicians Certification for Hospice Benefit," indicated the MDs signature on both lines There was no documented evidence to show AP 2 had signed Patient 15s ";Physicians Certification for Hospice Benefit." A review of Patient 15s claims for payment, indicated a claim for payment was submitted on June 1, 2023. 3c. A review of Patient 17s face sheet (a document that gives a summary of patients information), undated, indicated a start of care date of April 12, 2023, w ith a benefit period of April 12, 2023, to July 10, 2023 (First 90-day benefit period). Patient 17 had diagnoses that included Parkinsons disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement). A review of Patient 17s physicians order (by Attending Physician-AP 3) dated April 10, 2023, indicated a hospice referral to the agency. A review of Patient 17s ";Physicians Certification for Hospice Benefit," dated April 12, 2023, to July 10, 2023 indicated Patient 17 was in his first 90-day benefit period. Patient 17s ";Physicians Certification for Hospice Benefit," indicated two physician signature lines. One line indicated where the Hospice Medical Director (MD) should sign, and one line indicated where the Attending Physician (AP 3) should sign. Patient 17s ";Physicians Certification for Hospice Benefit," indicated the MDs signature on both lines There was no documented evidence to show AP 3 had signed Patient 17s ";Physicians Certification for Hospice Benefit." A review of Patient 17s claims for payment, indicated a claim for payment was submitted on May 12, 2023. During a concurrent interview and record review with the Medical Director (MD), Administrator (Admin), Director of Patient Care Services (DPCS), Compliance Officer (CO) and Administrator Designee (AD) on August 3, 2023, at 11:20 AM, Patient 15 and 17s ";Physicians Certification for Hospice Benefit," dated April 27, 2023, to July 25, 2023, and April 12, 2023, to July 10, 2023, respectively, was reviewed. The MD, Admin, DPCS, CO and AD verified the MD had signed as himself and as the Attending Physician for Patients 15 and 17. The MD, Admin, DPCS, CO and AD stated Patient 15 and 17s Attending Physicians AP 2 and AP 3 respectively had not signed Patient 15 and 17s ";Physicians Certification for Hospice Benefit," and the agency had submitted claims for payment. A review of the agencys policy and procedure titled, ";Certification of Terminal Illness," dated June 2022, indicated, ";PURPOSE: To ensure physician certification of terminal illness and authorization for hospice services, in accordance with applicable state and federal regulations and payer requirements. POLICY: At the time a patient and family/caregiver choose hospice care, the hospice Medical Director and the patient's attending physician, if any, will certify the patient's terminal illness. When certifying the patient as terminally ill, the hospice medical director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. ... PROCEDURE: 1. At time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, if applicable, examination of the patient. The patient's attending physician (if remaining as patient's attending physician) and/or the hospice Medical Director will sign the certification of terminal illness and authorization for hospice services forms. ... 4. The Medical Directors, and/or the attending physician's, signed and dated initial certification forms must be on file prior to billing the first claim. ..."