Every finding on record at Atlantic Care Hospice

Upon patient record review 2 of 14 (Patient #1, 5) did not have evidence in the patient record that the comprehensive assessment identifies the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process. Patient 1, 5: There is no evidence at the time of admission for hospice services, or any subsequent time, of assessment for spiritual needs related to the terminal illness.

Upon patient record review, 8 of 14 (Patient #1, 2, 4, 5, 6, 7, 8, 9) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient 1, 2, 4, 5, 6, 7, 8, 9: For all agency patients with oxygen ordered and in the home, the oxygen failed to appear on the medication list. (corrected onsite)

Upon patient record review, 3 of 14 (Patient #3, 5, 8) did not have evidence the plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions, including equipment and supply needs. Patient 3: The patient utilizes a walker for management of the terminal illness; however, this DME did not appear of the patient's plan of care. (corrected onsite) Patient 5: The patient utilizes a walker for management of the terminal illness; however, this DME did not appear of the patient's plan of care. (corrected onsite) Patient 8: The patient utilizes a walker and a wheelchair for management of the terminal illness; however, this DME did not appear of the patient's plan of care. (corrected onsite)

Upon client record review, 2 of 14 (Patient #1, 4) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: The plan of care indicates that a skilled nurse is to visit the patient 2 x weekly to provide needed care & services. However, during the weeks of 08.18.2024 and 09.29.2024 a nurse only visited the patient one time; there was no evidence of visit refusal by the patient or family. Additionally, during the week of 10.06.2024, a nurse made 3 visits to see the patient; there was no evidence of a PRN need or additional visit orders. Patient 4: The plan of care indicates that a skilled nurse is to visit the patient 1 x weekly to provide needed care & services. However, during the weeks of 08.18.2024 and 09.01.2024 there was no evidence that a nursing visit was made; there was no evidence of visit refusal by the patient or family.

Upon patient record review 2 of 14 (Patient #4, 8) did not have evidence documentation in the patient record that a hospice aide provides services that are: • Ordered by the interdisciplinary group • Included in the plan of care • Permitted to be performed under state law by such hospice aide • Consistent with the hospice aide training Patient 4: The plan of care indicates that an aide is to visit the patient 3 x weekly to provide needed care & services. However, during the weeks of 09.22.2024 and 09.29.2024 an aide only visited the patient 2 times; there was no evidence of visit refusal by the patient or family. Patient 8: The plan of care indicates that an aide is to visit the patient 3 x weekly to provide needed care & services. However, during the weeks of 07.28.2024, 08.11.2024, 08.18.2024, and 08.25.2024 an aide only visited the patient 2 times; there was no evidence of visit refusal by the patient or family.

Upon patient client record review, 1 of 14 (Patient #9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 9: The initial comprehensive nursing assessment notes that the patient is full code status. However, the POLST form, banner bar of the EMR, and all other subsequent documentation indicates the correct code status of DNR. The admission nurse failed to authenticate the patient's wishes via the POLST form and ensure appropriate documentation relating to code status.

Upon inpatient contract review, 1 of 3 (Huntington Healthcare Center) did not have evidence that the hospice retains responsibility for ensuring that the training of personnel who will be providing the patient's care in the inpatient facility has been provided and that a description of the training and the names of those giving the training are documented.

Based on observation, interview and record review, the hospice staff failed to review all medications the patients were taking and update the medication profiles with the currently used medications for 3 of 11 sampled patients (Patients 1, 5, and 9). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. Findings: a. A review of Patient 9's clinical record indicated a start of care date of 12/08/21, with primary diagnosis of 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 9's plan of care dated 12/08/21, indicated an order for the skilled nurse (SN) to visit 2 times a week for symptom management and to assess and evaluate disease progression, patient safety and comfort level. The SN was to review the medication profile of the patient every nursing visit, and to report to the physician and interdisciplinary group (IDG) any medication discrepancies. During a visit at skilled nursing facility (SNF) where Patient 9 resided on 2/04/22 at 10:24 a.m., the patient was observed lying in bed, awake with the head of bed elevated. Patient was unable to answer any questions asked. During an interview and record review of Patient 9's current medication regimen on 2/04/22 at 11:15 a.m., LVN 3 (SNF nurse) stated she currently gave these medications as ordered to the patient in the facility: -Multivitamins 1 tablet daily for supplement; -Vitamin D3 (a nutrient your body needs for building and maintaining healthy bones) 2000 units daily; -Lactulose (used to treat or prevent complications of liver disease) 20 grams/30 ml twice a day; -Potassium Chloride (a medicine used to prevent or treat low potassium levels in the body) 1/7.5 ml daily; -Midodrine (used to treat low blood pressure) 10 mg every 6 hours as needed for systolic blood pressure <100. There was no documented evidence that the medication profile provided by the hospice facility was updated to reflect Patient 9's current medication regimen for the current certification period. During an interview with the Administrator/Director of Nursing (ADM) on 2/08/22 at 10:15 am, she stated, "The nurse should ask during each home visit if there are any new medications or changes to the current medications. If so, the medication profile should be changed accordingly." During a review of the agency policy and procedure titled "Medication Profile revised April 2017)," indicated patients receiving medications administered by the hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. b. A review of Patient 5's "Face Sheet" form, indicated Patient 5 was admitted to the hospice on 8/13/2021 under routine care, with a primary diagnosis senile degeneration of brain (memory loss) and moderate protein-calorie malnutrition. The referring physician and medical director was Physician 1. A review of Patient 5's "Interdisciplinary Group (IDG) Conference Note/ Update to Plan of Care" (POC) form, dated 1/17/2022, indicated Hospice Aid (HA) was to visit twice per week. Skilled Nursing (SN) 2x/week. A review of Patient 5's "Medication Profile" for certification period of 12/11/2021 - 2/8/2022 indicated Patient 5's current medications: 1. Ambien 5 milligrams (mg) 1 tablet oral once a day, at night. 2. Ativan 0.5 mg 1 tablet oral every 6 hours as needed. 3. Seroquel 50 milligrams (mg) 1 tablet oral two times a day. 4. Trazodone Hydrochloride 50 mg 1 tablet oral once a day, at night 5. Aspirin 81 mg 1 tablet oral once a day 6. Ativan liquid 2mg/milliliter (ml) 0.5 ml sublingual every 6 hours as needed 7. Atorvastatin calcium 10 mg 1 tablet once a day 8. Ensure 30 grams 8 fluid ounces oral once a day 9. Fexofenadine HCL 60 mg 1 tablet oral once a day 10. Haloperidol 2mg/ml 0.5 ml sublingual every 6 hours as needed 11. Levsin 0.125 mg 1 tablet sublingual every 4 hours as needed 12. Lisinopril 10 mg 1 tablet oral once a day 13. Memantine HCL 5 mg 1 tablet oral two times a day 14. Morphine Sulfate 20mg/ml 0.25 ml sublingual every 4 hours as needed 15. Senna time 8.6 mg 1 tablet oral once a day 16. Tamsulosin HCL 0.4 mg 2 capsules oral once a day 17. Thick it 36 ounces nectar thick oral mix in all liquids 18. Tylenol 650 mg 1 suppository rectal every 6 hours as needed 19. Voltaren 101 grams thin layer cream topical apply to affected areas as needed. 20. Zofran ODT 4 mg 1 tablets sublingual every 6 hours as needed Treatments included: 1. Thicken all oral liquids with Thick-it Powder to obtain nectar thick consistency 2. Oxygen supplement at 2-4 Liters per minute (LPM)/Nasal Canula (NC) as needed for shortness of breath. During a joint home visit to Patient 5's home on 2/4/2021 at 9:35 a.m., with LVN 1, Patient 5 was noted lying on bed, with the side rails up. Wheelchair and bedside table at the side. LVN 1 took Patient 5's vital signs and asked Patient 5 if there were any concerns. LVN 1 stated that she reconciled Patient 5's medication every visit. During a concurrent interview with Patient 5's Care Giver 1 (CG1) stated the Administrator (ADM) called her and told her that she will be emailing an updated medication sheet and for her to print and place it in the Patient 5's folder. CG1 stated that she has not received the email yet but will print the new medication sheet when she does. Further interview with Patient 5's Care Giver 1 (CG1) on 2/4/2021 at 10:20 a.m., CG1 stated that she has been using the medication sheet provided by the hospice that was dated 12/10/2021. CG1 stated that there are two medications that were delivered last week (1/26/2022) that are not in Patient 5's medication list: Ativan and Ambien. CG1 stated, "They told me to follow the label." During a review of Patient 5's Medications indicated the medication profile used by the caregiver at the home was dated 12/10/2021, and did have the updated medication profile that would include the current medications ordered by the physician. A review of facility's policy titled, "Medication Profile" dated April 2017 indicated, "Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications ... Review of the medication profile ...will be considered when changing the pan of care." c. A review of Patient 1's admission record indicated the patient was admitted to the hospice on 1/16/2020, with diagnosis of atherosclerotic heart disease with angina pectoris with documented spasm and morbid obesity due to excess calories. The Plan of Care (POC) dated 12/2/2021 indicated Skilled Nursing (SN) visit was once every 2 weeks. The SN was to review the patient's medication every nursing visit and teach the family/PCG about the action and side effect and adverse effects of medication. On 2/3/2022, at 1:55 p.m., when Patient 1's home visit was conducted with Registered Nurse 1 (RN 1), Patient 1 was lying in a bed, alert and oriented, and was able to communicate. Family member 1 was next to Patient 1. At 2:30 p.m., Patient 1's medications were reviewed with RN 1 reconciling with the medication profile provided by the hospice. The following medications listed were not included in the medication profile. 1. Meclizine 25 milligram (mg) - one tablet as needed 2. Hydralazine HCL 100 mg - three times a day 3. Atorvastatin Calcium 40 mg -one tablet everyday (dated 1/22/2021) 4. Atorvastatin Calcium 80 mg -one tablet nightly (dated 4/2/2021) 4. Carvedilol 25 mg - one tablet two times a day 5. Clopidogrel Bisulfate 75 mg -one tablet everyday 6. Nifedipine ER 90 mg - one tablet everyday 7. Metformin HCL 1000 mg - one tablet two times a day During an interview with RN 1 at 2:45 p.m., stated she checked the medications and updated the medication profile two months ago. RN 1 stated the medications the patient was taking should have been assessed and updated in the medication profile, verified, and approved by the physician. A review of the agency's policy titled "Medication Profile" revised on April 2017 indicated the medication profile will be updated for each change to reflect current medications and new and/or discontinued medication.

Based on observation, interview and record review, the hospice facility failed to ensure the Condition of Participation for interdisciplinary group (IDG), care planning, and coordination of services was met by failing to: 1. Conduct IDG meeting participated by all disciplines to contribute to the patient's comprehensive and ongoing assessments, and care planning process. (refer to L541) 2. Ensure all hospice care and services furnished to patients and their families must follow an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire. (refer to L543) 3. Ensure that 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. (refer to L544) 4. Ensure the hospice interdisciplinary group (in collaboration with the individual's attending physician, (if any) must review, revise and document the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. (refer to L552) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Interdisciplinary group (IDG), care planning, and coordination of services to ensure highest quality of care are provided to the patients accurately assessed to receive hospice care and services.

Based on interview and record review, the hospice facility failed to ensure the interdisciplinary group (IDG) meetings were held to discuss the patients progress, ongoing assessment and care planning progress for 10 of 11 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 9, 10, and 11). This deficient practice has the potential to affect the patients continuity of care, care assessment, and care planning as identified by the the IDG. Findings: a. A review of Patient 1's admission record indicated the patient was admitted to the hospice on 1/16/2020, with diagnosis of atherosclerotic heart disease with angina pectoris (chest pain or discomfort that happens when some part of heart doesn't get enough blood and oxygen) with documented spasm and morbid obesity due to excess calories. On 2/3/2022, at 1:55 p.m., a home visit was conducted with the Registered Nurse 1 (RN 1) at Patient 1's residence. Patient 1 was observed lying in a bed, alert and oriented, and was able to communicate. Family member 1 (FM1)was next to Patient 1. During an interview with FM1 at the same time, she stated Patient 1's weight was 270 pounds 9 months ago, but 190 pounds now. At 2:10 p.m., during an interview with Patient 1, she sated she did not have any pain or wound, and she did not need services from hospice aide (HA), chaplain, MSW, and volunteer. Patient 1 stated she only needed a registered nurse (RN) who gave instructions, checked vital signs, and medications. A review of IDG Conference Note/Update to Plan of Care dated 1/8/2022, indicated the services for chaplain, Aide, and volunteer were declined during the start of care (SOC) on 16/2020. The Medical Social Worker (MSW) was to evaluate from 1/16/2020 to 4/14/2020. It indicated two visits per month for "other" visit. A review of Patient 1's clinical record indicated the IDG/Plan of Care (POC) meeting was held on the following days: 1. IDG/POC dated 8/26/2021, indicated the SN was to provide teaching on disease process and prognosis, educate patient on importance of care plan and medication regimen. The MSW will remain available for further assistance, chaplain and volunteer services were declined. It indicated the LVN attended the meeting identified by a signature. The other IDG members were missing signatures such as Medical Director (MD), RN, and MSW. There was no documented evidence the POC was reviewed in collaboration with all members of the IDG. 2. IDG/POC dated 9/9/2021, indicated the SN was to provide teaching on disease process and prognosis and educate patient on importance of care plan and medication regimen. The MSW will remain available for further assistance, chaplain and volunteer services were declined. It indicated the LVN attended the meeting identified by a signature. The other IDG members were missing signatures such as Medical Director (MD), RN, and MSW. There was no documented evidence the POC was reviewed in collaboration with all members of the IDG. 3. IDG/POC dated 9/23/2021, indicated the SN was to provide teaching on disease process and prognosis, educate patient on importance of care plan and medication regimen. The MSW will remain available for further assistance, chaplain and volunteer services were declined. It indicated the LVN attended the meeting identified by a signature. The other IDG members were missing signatures such as Medical Director (MD), RN, and MSW. There was no documented evidence the POC was reviewed in collaboration with all members of the IDG 4. Recertification Physician's orders and IDG Notification dated 9/27/2021, indicated RN visits every 14 days, no CHHA, no LVN visits per patient and family's request. It indicated the RN attended the meeting as identified by a signature. The MD and MSW were blank. There was no documented evidence the POC was reviewed in collaboration with all members of the IDG. 5. The Plan of Care dated 12/2/2021 indicated Skilled Nursing visit was once every 2 weeks. There were no signatures of the MD and RN. There was no documented evidence the POC was reviewed in collaboration with all members of the IDG. On 2/7/2022, at 3:50 p.m., during an interview with the Director of Patient Care Services (DPCS), she stated she was not able to provide the documented evidence the IDG members including the MD, RN and MSW had participated in the IDG meeting on above days. The DPCS stated all the IDG members should have been participated to the IDG meeting on above days. b. A review of Patient 2's admission record indicated the patient was admitted to the hospice on 6/1/2021, with diagnosis of cerebral infarction (pathologic process that results in an area of necrotic tissue in the brain) due to unspecified occlusion or stenosis of left cerebellar artery. A review of the IDG Conference note/Update to Plan of Care dated 1/27/2022 indicated Skilled Nurse (SN) visits were two times per week, MSW visit was on evaluation, and Aide visit(s) two times per week. It indicated the RN attended as identified by a signature. There were no signatures of the chaplain, volunteer, MSW, and Medical Doctor. There was no documented evidence the POC was reviewed in collaboration with all members of the IDG. On 2/7/2021, at 4 p.m., during an interview with the DPCS, she stated the services of chaplain and the volunteer was declined. The DPCS was not able to provide the documented evidence the Medical Doctor and the MSW had participated in the IDG meeting on 1/27/2022. c. A review of Patient 3's admission record indicated the patient was admitted to the hospice on 8/21/2021, with diagnosis of chronic obstructive pulmonary disease (COPD). A review of the "IDG Conferences Note/Update to Plan of Care" dated 1/27/2022, indicated Skilled Nurse (SN) was to visit once per week and the MSW was to do evaluation. The spaces for chaplain, Aide, and volunteer were blank. There was a RN's signature, but the spaces for the MSW, Chaplain, Aide, volunteer, and the Medical doctor's signatures were blank. There was no documented evidence the POC was reviewed in collaboration with all members of the IDG. On 2/7/2022, at 4 p.m., during an interview with the DPCS, she stated the services of chaplain, aide, and the volunteer were declined. The DPCS was not able to provide the documented evidence the Medical doctor and the MSW had participated in the IDG meeting on 1/27/2022. d. A review of Patient 4's admission record indicated the patient was admitted to the hospice on 5/5/2020, with diagnosis of severe protein-calorie malnutrition and malignant neoplasm of pelvis. A review of the "IDG Conference Note/Update to Plan of Care" dated 5/5/2020, 6/18/2020, 7/29/2020, and 8/13/2020 indicated the SN visit once a week. The services of chaplain, Aide, volunteer were declined. There were RN's signatures, but the spaces for the Medical doctor's signatures were blank. There was no documented evidence the POC was reviewed in collaboration with all members of the IDG On 2/8/2022, at 11:10 a.m., during an interview with the DPCS, she was not able to provide the documented evidence the Medical doctor had participated in the IDG meeting on 5/5/2020, 6/18/2020, 7/29/2020, and 8/13/2020. The DPCS, stated all the disciplines who provide care/services should participate the IDG meeting and sign. A review of the agency's policy titled "Interdisciplinary Group Meeting" revised on April 2017 indicated the hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice clinical supervisor/nursing supervisor. d. A review of Patient 5's "Face Sheet" form, indicated Patient 5 was admitted to the hospice on 8/13/2021 under routine care. The primary diagnosis senile degeneration of brain (memory loss) and moderate protein-calorie malnutrition. The referring physician and medical director was Physician 1. A review of Patient 5's "Physician's Certification for Hospice Benefit" (CTI - document that indicated a physician certified the patient's eligibility for hospice benefits), dated 8/13/2021 to 10/11/2021 indicated Physician 1 certified that Patient 5 was still considered to be terminally ill and had a life expectancy of six (6) months or less if the terminal illness runs its normal course. A review of Patient 5's "Interdisciplinary Group (IDG) Conference Note/ Update to Plan of Care" (POC) form, dated 1/17//2022, indicated Hospice Aid (HA) was to visit twice per week, and Skilled Nursing (SN) 2x/week. A review of Patient 5's "Comprehensive Hospice Assessment" dated 8/13/2021 indicated Patient 5's Karnofsky Performance Status Scale (KPSS - functional impairment scale) was at 40% (disabled, requires special care and assistance. Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly). Patient 5's Palliative Performance Scale (PPS - assesses functional performance and determines progression toward end of life) was at 40% (mainly in bed, unable to do most activity extensive disease, mainly assistance, normal or reduce intake, full or drowsy, confusion conscious level). It also indicated the patient's weight of 115 pounds. A review of Patient 5's medical record with the hospice Administrator (ADM) on 2/7/2022, at 2 p.m., indicated Patient 5 had three Interdisciplinary Group (IDG) meetings since admission (8/13/2021). These dates included: 10/8/2021: signed by Registered Nurse 2 (RN2) 1/17/2022: signed by Administrator (ADM) and Physician 1. 1/27/2022: signed by ADM and Physician 1. The other members of the IDG indicated no evidence of attendance during these meetings. e. A review of Patient 6's "Face Sheet" form, indicated Patient 6 was admitted to the hospice on 7/30/2020 under routine care, with a primary diagnosis of unspecified cirrhosis (disease of the liver) of liver, unspecified severe protein-calorie malnutrition, type 2 diabetes mellitus (elevated blood sugar levels), and Dementia (memory loss) in other diseases. The referring physician and medical director was Physician 1. A review of Patient 6's "Physician's Certification for Hospice Benefit" (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 7/30/2020 to 10/27/2020 and 1/21/2022 to 3/21/2022, indicated Physician 1 certified that Patient 6 was considered to be terminally ill and has a life expectancy of six (6) months or less if the terminal illness runs its normal course. A review of Patient 6's "Plan of Care" (POC) form, dated 1/14//2022, indicated HA was to visit twice per week. SN 1x/week. A review of Patient 6's "Recertification Comprehensive Hospice Assessment" dated 1/14/2022, in the space Narrative/Summary it indicated Patient 6 was eligible for hospice care based on LCD guidelines. A review of Patient 6's medical record with the hospice Administrator (ADM) on 2/7/2022, at 2 p.m., indicated Patient 6 had six Interdisciplinary Group (IDG) meetings in 2021 and two in 2022. These dates included: 1/15/2021: signed by Administrator (ADM) and Physician 1 3/26/2021: signed by ADM and Physician 1 5/20/2021: signed by ADM and Physician 1 7/15/2021: signed by ADM and Physician 1 9/9/2021: signed by ADM and Physician 1 11/19/2021: signed by ADM 1/14/2022: signed by ADM and Physician 1 1/27/2022: signed by ADM and Physician 1 The other members of the IDG indicated no evidence of attendance during these meetings. f. A review of Patient 7's "Face Sheet" form, indicated Patient 7 was admitted to the hospice on 6/10/2021 under routine care, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD- group of diseases that cause airflow blockage and breathing-related problems.). The referring physician and medical director was Physician 1. A review of Patient 7's "Physician's Certification for Hospice Benefit" (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 6/10/2021 to 9/7/2021 and 12/7/2021 to 2/4/2022, indicated Physician 1 certified that Patient 7 was still considered to be terminally ill and had a life expectancy of six (6) months or less if the terminal illness runs its normal course. A review of Patient 7's "Plan of Care" (POC) form, dated 12/7/2021, indicated HA was to visit twice per week, SN 1x/week, and MSW evaluation only starting on 12/7/2021. A review of Patient 7's "Recertification Comprehensive Hospice Assessment" dated 12/7/2021, indicated Patient 7 was alert and oriented to person and place, and able to make needs known. It also indicated Patient 7 was receiving routine care, fatigues easily, up as tolerated on wheelchair. In the space Narrative/Summary it indicates MD made aware of the patient current condition. The patient was still eligible for hospice care. A review of Patient 7's medical record with the hospice Administrator (ADM) on 2/7/2022, at 2 p.m., indicated Patient 7 had two Interdisciplinary Group (IDG) meetings in 2021 and one in 2022. These dates included: 9/2/2021: signed by Administrator (ADM) and Medical Social Worker (MSW) 12/7/2021: signed by ADM 1/27/2022: signed by ADM The other members of the IDG indicated no evidence of attendance during these meetings. During an interview on 2/7/2022 at 2 p.m. with the hospice Administrator (ADM), the ADM stated that IDG meetings are supposed to be held every 14 days. ADM stated that not all signatures are in the IDG meetings, "they are supposed to sign electronically". During a telephone interview on 2/8/2022, at 11:50 a.m., with Physician 2, Physician 2 stated she has been working at hospice facility for, "three years or so". Physician 2 stated she attends the IDG meetings virtually or via speaker phone. Physician 2 stated she signs the IDG Meeting through JNCloud (hospice facility computer/electronic program). Physician 2 was not able to recall when she attended the last IDG meeting, "I can't remember, I have to check my agenda". During an interview on 2/8/2022 at 3:40 p.m. with ADM, stated ADM, Medical Director, Registered Nurse or Licensee Vocational Nurse, Case Manager, and Clinical Social Worker attended the IDG meetings. ADM was asked if the Chaplain attended the IDG meetings. ADM stated, "We do have a Chaplain, but he was not actively seeing patients right now." ADM stated that the Chaplain had not seen patients, "for the past year". ADM stated IDG meeting are supposed to be signed, "after the meeting, electronically, but it takes them long to sign. I don't know why". A review of facility's policy and procedure titled "Interdisciplinary Group Meeting" dated April 2017, indicated each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequent than every 15 days or more frequently if the patients condition requires. The hospice Medical Director and all hospice interdisciplinary group members will be present ... Members at the interdisciplinary group meeting will sign an attendance from that will be kept by the hospice Clinical Supervisor/Nursing Supervisor. A review of facility's policy and procedure titled "Interdisciplinary Group Coordination of Care" dated April 2017 indicated the interdisciplinary group (in collaboration with the attending physician, if any) will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every two (2) weeks. A review of facility's policy and procedure titled "Interdisciplinary Group Membership and Responsibilities" dated April 2017 indicated the hospice interdisciplinary team/group members will include, at a minimum: A Physician B. Registered Nurse C. Social Worker D. Pastoral or other counselor. A review of facility's policy and procedure titled "Entries into the Clinical Record" dated April 2017 indicated documentation in the clinical record will be timely ... Based on interview and record review, the hospice agency (HA) failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were held by all the members of interdisciplinary group to discuss the patient's comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process, ongoing assessments and care planning process for four of 13 sampled patients, (Patients 3, 5, 12 and 13). This deficient practice has a potential for the patient's progress or decline will not be identified by the IDG, interventions will not be implemented, and patient care goals will not be achieved. Findings: a. A review of Patient 3's clinical record indicated a start of care (SOC) date of 12/22/2020, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 8/1/2022, indicated skilled nurse (SN) frequency of visits of once per week and one as needed, Hospice Aide once per week, Social Worker (MSW) and Spiritual Counsellor (SC) on initial comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), recertification, and as needed. Volunteer service was declined. A review of Patient 3's "POC/IDG Review" dated 7/5/2022, 7/18/2022, and 8/1/2022, indicated the spaces for MSW signature were left blank. A review of the "IDG Log" dated 7/5/2022, 7/18/22, and 8/1/2022 indicated there was no MSW signature. During an interview with the Director of Patient Care Services (DPCS), on 9/12/2022, at 2:35 p.m., she stated that the IDG team meeting should be held every two weeks with participation of all the IDG members (Medical doctor, DPCS, SN, MSW and spiritual counselor) even though the patient had refused any of above service. She stated when the IDG members participated in the IDG meeting, they should have signed right away. The DPCS was not able to provide the documented evidence all the IDG members had participated in the IDG meeting for 7/5/2022, 7/18/2022, and 8/1/2022. c. A review of Patient 5's clinical record indicated Patient 5 started hospice care on 12/28/21, with a terminal diagnosis of COPD. It indicated the Medical Director was the referring/attending/patient choice doctor. A review of the POC/IDG Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The SN visit was once a week and as needed. The MSW visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. A review of the "POC/IDG Review" dated 7/5/2022, 7/18/22, 8/1/2022, 8/15/2022, 8/29/2022 indicated the spaces of signature for the social worker, were blank. A review of the "IDG Log" dated 7/5/2022, 7/18/22, 8/1/2022, 8/15/2022, 8/29/2022 did not indicate signatures of the social worker. During an interview with the DPCS on 9/12/2022, at 3 p.m., she was not able to provide the documented evidence that the social worker had participated in the POC/IDG meetings. d. A review of Patient 12's clinical record indicated the patient was admitted to the HA on 6/27/2022, with diagnosis of unspecified COPD. A review of Patient 12's POC/IDG, dated 7/05/2022, SN frequency of visits of once per week and one as needed. The HA, MSW, SC, and volunteer service were declined. A review of Patient 12's POC/IDG meeting record indicated blank spaces, no signatures to indicate the Medical MSW had participated the meetings on 7/05/2022, 7/18/2022/, 8/01/2022 and 8/15/2022. e. A review of Patient 13's clinical record indicated the patient was admitted to the HA on 6/28/2022, with diagnosis of unspecified COPD. A review of Patient 13's POC/IDG, dated 7/05/2022, indicated RN frequency of visits to once every two weeks plus one visit as needed, and LVN visit to once a week plus one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of Patient 13's POC/IDG meeting record indicated blank spaces, no signatures to indicate the MSW had participated the meetings on 7/05/2022, 7/18/2022/, 8/01/2022, 8/15/2022 and 8/29/2022. During an interview with the DPCS, on 9/12/2022, at 2:35 p.m., she stated that the IDG team meeting should be held every two weeks with participation of all the IDG members (Medical doctor, DPCS, SN, MSW and spiritual counselor) even though the patient had refused any of above service. She stated when the IDG members participated in the IDG meeting, they should have signed right away. The DPCS was not able to provide the documented evidence that all the IDG members had participated in the IDG meeting for Patient 12 and 13 on the above days. A review of the agency's policy and procedure titled "Interdisciplinary Group Meeting," revised April 2017, indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care. Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. Members of the interdisciplinary group meeting will sign an attendance from that will be kept by the hospice Clinical Supervisor/Nursing Supervisor. A review of the agency's policy titled, "Interdisciplinary Group Coordination of Care" revised in April 2017, indicated the care will be provided by an interdisciplinary group made up of physicians, nurses, social workers, certified hospice aides, homemakers, clergy, counselors, volunteers, and therapists. The interdisciplinary group (in collaboration with the attending physician, if, any) will conduct assessment, develop and update the plan of care, and review the effectiveness of care at minimum of every two (2) weeks.

Based on observation, interview, and record review, the hospice facility failed to provide skilled nursing (SN) services in accordance with the plan of care established by the IDG for 8 of 11 sampled patients (Patient 1, 2, 3, 4, 6, 7, 9, and 11). This deficient practice has the potential to affect the patients health status and provision of quality of care to the patients certified to receive hospice/palliative care. Findings: a. A review of Patient 1's admission record indicated the patient was admitted to the hospice facility on 1/16/2020, with diagnosis of atherosclerotic heart disease with angina pectoris (chest pain or discomfort that happens when some part of heart doesn't get enough blood and oxygen) with documented spasm and morbid obesity due to excess calories. On 2/3/2022, at 1:55 p.m., during Patient 1's home visit with Registered Nurse 1 (RN 1), Patient 1 was observed lying in a bed, alert and oriented, and was able to communicate well. Family member 1 was next to Patient 1. At 2:10 p.m., during an interview with Patient 1, she stated she felt dizziness. A review of Plan of Care (POC) dated 12/2/2021 indicated the Skilled Nurse (SN) was to visit once every two weeks to instruct proper and safe use of oxygen, assess pain and signs of hyperglycemia, educate the patient/primary caregiver, and encourage activity. A review of Patient 1's clinical record indicated there was no SN visit note after 12/30/2021. On 2/8/2022, at 1 p.m., during an interview with the Director of Patient Care Services (DPCS), she was not able to provide the SN visit notes and signed sheet by the patient/PCG to confirm the SN visited Patient 1 after 12/20/2021. On 2/11/2022, at 4 p.m., during a telephone interview with Family member 2, she stated she could not remember when the SN last visited Patient 1. b. A review of Patient 2's admission record indicated the patient was admitted to the hospice facility on 6/1/2021, with diagnosis of cerebral infarction (pathologic process that results in an area of necrotic tissue in the brain) due to unspecified occlusion or stenosis of left cerebellar artery. A review of the IDG Conference note/Update to Plan of Care dated 1/27/2022 indicated Skilled Nurse (SN) visits two times per week, MSW visit for initial evaluation, and hospice aide visit(s) two times per week A review of Patient 2's clinical record indicated there were no SN visit notes after 12/20/2021. There was one SN visit note instead of two visit notes in the record on following days: 1. 12/8/2021 - the week from 12/5/2021 to 12/11/2021 2. 12/15/2021- the week from 12/12/2021 to 12/18/2021 3. 12/20/2021 - the week from 12/19/2021 to 12/25/2021 On 2/8/2022, at 1 p.m., during an interview with the DPCS, she was not able to provide the SN visit notes and the documented evidence (such as signed sheet by the patient/PCG which confirmed SN visit) to indicate the SN had visited Patient 2 after 12/20/2022 and the SN had visited twice a week instead of once a week. c. A review of Patient 3's admission record indicated the patient was admitted to the hospice on 8/21/2021, with diagnosis of chronic obstructive pulmonary disease (COPD). A review of the "IDG Conference Note/Update to Plan of Care" dated 1/27/2022, indicated Skilled Nurse (SN) was to visit once per week and the MSW was to do initial evaluation. The spaces for chaplain, Aide, and volunteer were blank. A review of Patient 3's clinical record indicated no evidence of SN visit notes for the week of 12/26/2021 to 1/1/2022. On 2/8/2022, at 1 p.m., during an interview with the DPCS, she was not able to provide the SN visit note and any documented evidence to indicate SN had visited Patient 3 from 12/26/2021 to 1/1/2022. d. A review of Patient 4's admission record indicated the patient was admitted to the hospice on 5/5/2020, with diagnosis of severe protein-calorie malnutrition and malignant neoplasm of pelvis. A review of the "IDG Conference Note/Update to Plan of Care" dated 5/5/2020, 6/18/2020, 7/29/2020, and 8/13/2020 indicated the SN visit was once a week. The services of chaplain, Aide, and volunteer were declined. A review of Patient 4's clinical record indicated there was no SN visit note after 12/16/2021. On 2/8/2022, at 11:30 a.m., during a telephone interview with LVN 4, she stated she could not visit Patient 4 because it was hard to reach the patient. LVN 4 stated she could not remember when was her last visit for Patient 4. On 2/8/2022, at 1 p.m., during an interview with the Director of Patient Care Services (DPCS), she was not able to provide the SN visit notes and the documented evidence indicating the SN had visited Patient 1 after 12/16/2021. The DPCS stated when missed visit happened, the SN should have notified the IDG and supervisor, and followed up and documented in the record. A review of the agency's policy titled " The Plan of Care" revised in April 2017 indicated the care provided to the patient must be in accordance with the plan of care. A review of the agency's policy titled "Miss Visits" revised in April 2017 indicated a missed visit will be rescheduled the same week if possible and will be documented in the clinical record. The clinician should notify the IDG and clinical supervisor of the missed visit and the reason for missed visit. e. A review of Patient 6's "Face Sheet" form, indicated Patient 6 was admitted to the hospice on 7/30/2020 under routine care, with a primary diagnosis unspecified cirrhosis (disease of the liver) of liver, unspecified severe protein-calorie malnutrition, type 2 diabetes mellitus (elevated blood sugar levels), and dementia (memory loss) in other diseases. Physician 1, was the referring physician and the medical director of the hospice facility. A review of Patient 6's "Physician's Certification for Hospice Benefit" (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 7/30/2020 to 10/27/2020 and 1/21/2022 to 3/21/2022, indicated Physician 1 certified that Patient 6 was considered to be terminally ill and had a life expectancy of six (6) months or less if the terminal illness runs its normal course. A review of Patient 6's "Plan of Care" (POC) form, dated 1/14//2022, indicated Hospice Aid (HA) was to visit twice per week. Skilled Nursing (SN) 1x/week, Medical Social Worker (MSW), Chaplain, and Volunteer were declined on 1/21/2022. A review of Patient 6's medical record with the hospice Administrator (ADM) on 2/7/2022, at 2 p.m., indicated Patient 6 was missing a SN visit notes for the week of 1/23/2022 to 1/29/2022. There were no available "Route Sheets" for Patient 6 for the month of January 2022. f. A review of Patient 7's "Face Sheet" form, indicated Patient 7 was admitted to the hospice on 6/10/2021 under routine care, with a primary diagnosis of chronic obstructive pulmonary disease (COPD- group of diseases that cause airflow blockage and breathing-related problems.). The referring physician and medical director was Physician 1. A review of Patient 7's "Physician's Certification for Hospice Benefit" (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 6/10/2021 to 9/7/2021 and 12/7/2021 to 2/4/2022, indicated Physician 1 certified that Patient 7 was still considered to be terminally ill and had a life expectancy of six (6) months or less if the terminal illness runs its normal course. A review of Patient 7's "Plan of Care" (POC) form, dated 12/7/2021, indicated Hospice Aid (HA) was to visit twice per week. Skilled Nursing (SN) 1x/week, MSW for evaluation only starting on 12/7/2021. A review of Patient 7's "Recertification Comprehensive Hospice Assessment" dated 12/7/2021, indicated Patient 7 was alert and oriented to person and place, and able to make needs known. It also indicated Patient 7 was receiving routine care, fatigues easily, up as tolerated on wheelchair. A review of Patient 7's medical record with the hospice Administrator (ADM) on 2/7/2022, at 2 p.m., indicated Patient 7 was missing a SN visit notes for the weeks of 12/5/2021 to 12/11/2021 and 12/12/2021 to 12/18/2021. There were no available "Route Sheets" for Patient 7 for two weeks (12/5/2021 to 12/11/2021 and 12/12/2021 to 12/18/2021). During an interview on 2/7/2022 at 2 p.m. with the hospice Administrator (ADM), the ADM stated, "we give them 48 hours to document", when asked how long you give staff to document a visit. During an interview on 2/8/2022 at 3:40 p.m. with ADM stated the process for missed visit should be, " Be documented with the reason why they were missed. We call the caregiver or the patient to re-schedule". A review of facility's policy and procedure titled "Entries into the Clinical Record" dated April 2017 indicated documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. A review of facility's policy and procedure titled "Missed Visits" dated April 2017 indicated missed visits will be communicated to the Interdisciplinary Group at the IDG Meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. g. A review of Patient 9's clinical record indicated a start of care date of 12/08/21, with primary diagnosis of 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 9's plan of care dated 12/08/21 indicated Skilled Nursing (SN) was to make 2 visits a week to instruct proper and safe use of oxygen, assess response to medications and treatments, assess patient's swallowing ability, and educate the patient/primary caregiver on fall prevention strategies. A review of Patient 9's clinical record indicated there was no SN visit note from the start of care date of 12/08/21 up to the week ending 1/1/2022. On 2/8/2022, at 10:15 a.m., during an interview with the Administrator/Director of Nursing (ADM), the ADM was not able to provide the SN visit notes and the documented evidence indicating the SN had visited Patient 9 from 12/08/21 to 1/01/2022. h. A review of Patient 11's clinical record indicated a start of care date of 6/22/21, with primary diagnosis of senile degeneration of brain (the mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age) and unspecified severe protein-calorie malnutrition. A review of Patient 11's plan of care dated 12/19/21 indicated Skilled Nursing (SN) was to make 2 visits a week to assess pain and response to medications, assess alteration in mobility, and to educate and instruct patient and caregivers about safety measures to prevent fall and injury. A review of Patient 2's clinical record indicated there was no SN visit notes after 10/29/21. On 2/8/2022, at 10:15 a.m., during an interview with the Administrator/Director of Nursing (ADM), the ADM was not able to provide the SN visit notes and the documented evidence indicating the SN had visited Patient 11 after 10/29/21.

Based on observation, interview and record review, the skilled nurse (SN) failed to ensure the patients/caregivers were provided education/instruction regarding the use of an oxygen concentrator, side effects of medications and the use of comfort kits (a prescribed set of medications that are kept in a patient's home to treat any distressing symptoms as quickly as possible) for 2 of 11 sampled patients (1, and 5). This deficient practice can place the patients' health status at risk due to the delay in identifying side effects of the medications and delayed response/relief to patient's distressing symptoms and discomfort. Findings: a. A review of Patient 1's admission record indicated the patient was admitted to the hospice on 1/16/2020, with diagnosis of atherosclerotic heart disease with angina pectoris (chest pain or discomfort that happens when some part of heart doesn't get enough blood and oxygen) with documented spasm and morbid obesity due to excess calories. The POC dated 12/2/2021 indicated SN visit was once every 2 weeks. The SN was to review the patient's medication every nursing visit and teach the family/PCG about the actions and side effects and adverse effects of medication. On 2/3/2022, at 1:55 p.m., during Patient 1's home visit with RN 1, Patient 1 was observed lying in a bed, alert and oriented, and was able to communicate. Family member 1 was next to Patient 1. At 2:10 p.m., during an interview with Patient 1, sated she had dizziness. At 2:20 p.m., during an interview with Patient 1 and Family member 1, both stated they were not provided education/instruction regarding side effects of medications. At 2:30 p.m., Patient 1 was taking 18 different medications. Medications were reviewed with RN 1 by comparing the medication profiles. During a review of the medication profiles revealed no indication the side effects of these 18 medications were identified. On 2/3/2022, at 2:45 p.m., when asked to locate the comfort kit, Family member 1 called Family member 2 who was the primary caregiver (PCG). During a telephone interview with Family member 2 at the same time, she stated instructions regarding use of the comfort kit was not provided to Patient 1. On 2/7/2022, at 3:50 p.m., during an interview with the Director of Patient Care Services (DPCS), she stated the SN should have provided written teaching materials including actions and side effects of medications the patient was taking. The DPCS also stated the agency had provided the Comfort kit when Patient 1 was admitted to the hospice. The DPCS was not able to provide the documented evidence the Comfort kit and the education/instruction regarding the medications in the Comfort kit was provided to Patient 1 and/or PCG. A review of the agency's policy titled "Medication Profile" revised on April 2017 indicated each patient and/or family/caregiver will receive appropriate written teaching materials for specific medications he/she is receiving. The material should contain information on actions of the medication, potential side effects, contraindications, and any special instructions when taking specific medication. When asked policy about the "Comfort kit", the DPCS stated the agency did not have policy regarding "Comfort kit". b. A review of Patient 5's "Face Sheet" form, indicated Patient 5 was admitted to the hospice on 8/13/2021, with a primary diagnosis senile degeneration of brain (memory loss) and moderate protein-calorie malnutrition. The referring physician and medical director was Physician 1. A review of Patient 5's "Interdisciplinary Group (IDG) Conference Note/ Update to Plan of Care" (POC) form, dated 1/17//2022, indicated Hospice Aid (HA) was to visit twice per week. Skilled Nursing (SN) 2x/week. It also indicated Patient 5 has oxygen supplement at 2-4 Liters per minute (LPM)/Nasal Canula (NC) as needed for shortness of breath. A review of Patient 5's Physician's Certification for Hospice Benefit (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 12/11/2021 to 2/8/2022, indicated Physician 1 certified that Patient 5 was still considered to be terminally ill and had a life expectancy of six (6) months or less if the terminal illness runs its normal course. A joint home visit was conducted on 2/4/2022, at 9:30 a.m., to Patient 5's home with License Vocational Nurse 1 (LVN 1). Patient 5 was noted lying on bed with side rails up. Wheelchair and side table noted by beside. LVN 1 proceeded to assess Patient 5 and took his vital signs. An interview on 2/4/2022 at 9:45 a.m. with LVN 1, LVN 1 was asked if Patient 5 used oxygen (O 2). LVN 1 stated, "I don't think so". LVN 1 proceeded to look around room and in closet, where she found a O 2 concentrator and O 2 cylinder. LVN 1 was asked if she had educated/instructed CG1 on the use of O 2. LVN 1 stated, "Yes, I told her that she needed to check his vital signs, blood pressure before lunch and before he takes his blood pressure medication. LVN 1 was asked if she instructed/educated CG1 on how and when to administer O 2. LVN 1 stated, "No". LVN 1 was asked if Patient 5 had a "Comfort Kit". LVN 1 stated, "No, I don't think so. The daughter takes care of that. Is that something the hospice agency does?" An interview on 2/4/2022 at 10:20 a.m. with CG1, CG1 stated Patient 5 arrived at her home on December 14, 2022. CG1 was asked if Patient 5 had a "Comfort Kit". CG1 was unaware of what a "Comfort Kit was. CG1 stated, "no, the daughter brought some things, but she didn't bring that". CG1 was asked if she had received education or instructions on how to check Patient 5's O 2 saturation. CG1 stated, "No, (LVN 1) told me to check his blood pressure before I gave him his blood pressure medication, before lunch. (LVN 1) is only concern about his blood pressure. His daughter told me that the hospice was going to deliver oxygen but told me that he doesn't really need it". CG1 was asked if she was educated/instructed on how to use the O 2 concentrator or the O 2 cylinder. CG1 stated, "No. He (Patient 5) is the only patient in here that was hospice or Oxygen". An interview on 2/7/2022 at 2 p.m. with Administrator (ADM), ADM stated she was unable to find any documentation on Comfort Kit or Oxygen use and education in Patient 5's medical record. ADM stated, "I don't see any note saying that the caregiver, was educated on the Oxygen use". A review of facility's policy and procedure titled "Hospice Nursing Care, dated April 2017 indicates "the hospice nurse will, provide specialized hospice training to other staff, family/caregiver to ensure adequate care. Assess the ability of the caregiver to meet the patient's immediate needs upon admission and throughout care. Patient and family/caregiver education and training activities will be initiated and continued throughout the course of care. A review of facility's policy and procedure titled "Patient Education Process" dated April 2017 indicated "to provide guidelines for giving specific instruction and information to patients and family/caregivers regarding hospice services."

Based on observation, interview and record review, the hospice facility failed to ensure the patients written plans of care (POC) were reviewed and revised by the interdisciplinary group (IDG) every 15 days for 10 of 11 patients (1, 2, 3, 4, 5, 6, 7, 9, 10, and 11). This deficient practice had the potential to result in the non-continuity of the patient care assessment and care planning identified by the IDG in order to meet the needs and achieve the patients care goals. Findings: a. A review of Patient 1's admission record indicated the patient was admitted to the hospice on 1/16/2020, with diagnosis of Atherosclerotic heart disease with angina pectoris (chest pain or discomfort that happens when some part of heart doesn't get enough blood and oxygen) with documented spasm and morbid obesity due to excess calories. On 2/3/2022, at 1:55 p.m., when Patient 1's home visit was conducted with Registered Nurse 1 (RN 1), Patient 1 was lying in a bed, alert and oriented, and was able to communicate well. Family member 1 was next to Patient 1. A review of Patient 2's clinical record indicated the IDG/POC Conference were conducted on 8/26/2021, 9/9/2021, 9/23/2021,9/27/2021, 12/2/2021, and 1/8/2022. There was no documented evidence the IDG/POC meeting was conducted between 9/27/2021 to 12/2 2021, and between 12/2/2021 to 1/8/2022. There was no documented evidence the IDG/POC meeting was conducted after 1/8/2022 until 2/3/2022. b. A review of Patient 2's admission record indicated the patient was admitted to the hospice on 6/1/2021, with diagnosis of cerebral infarction (pathologic process that results in an area of necrotic tissue in the brain) due to unspecified occlusion or stenosis of left cerebellar artery. A review of Patient 2's clinical record indicated the IDG/POC conferences were conducted on 6/1/2021 and 1/27/2022. There was no documented evidence the IDG/POC meetings were conducted between 6/1/2021 to 1/27/2022. c. A review of Patient 3's admission record indicated the patient was admitted to the hospice on 8/21/2021, with diagnosis of chronic obstructive pulmonary disease (COPD). A review of Patient 3's clinical record indicated the IDG/POC Conference were conducted on 11/13/2021 and 1/27/2022. There was no documented evidence the IDG/POC meetings were conducted between 8/21/2021 to 11/13/2021 and 11/13/2021 to 1/21/2022. d. A review of Patient 4's admission record indicated the patient was admitted to the hospice on 5/5/2020, with diagnosis of severe protein-calorie malnutrition and malignant neoplasm of pelvis. A review of Patient 3's clinical record indicated the IDG/POC conference were conducted on 5/5/2020, 6/18/2020, 7/29/2020, 8/13/2020, 10/21/2020, 12/20/2020, 2/24/2021, 4/21/2021, 6/16/2021, 8/13/2021, and 10/21/2021. There was no documented evidence the IDG/POC meetings were conducted between 8/13/2020 to 10/21/2020, 10/21/2020 to 12/20/2020, 12/20/2020 to 2/24/2021, 2/24/2021 to 4/21/2021, 4/21/2021 to 6/16/2021, 6/16/2021 to 8/13/2021, 8/13/2021 to 10/21/2021. Also, there was no documented evidence IDG/POC meetings were conducted after 10/21/2021 until 2/3/2022. On 2/8/2022, at 11:10 a.m., during an interview with the DPCS, she was not able to provide the documented evidence the IDG/POC meetings were conducted every 15 days for Patients 1, 2, 3, and 4 during these period of time. A review of the agency's policy titled "Interdisciplinary Group Meeting" revised on April 2017 indicated each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. e. A review of Patient 5's "Face Sheet" form, indicated Patient 5 was admitted to the hospice on 8/13/2021 under routine care, with a primary diagnosis senile degeneration of brain (memory loss) and moderate protein-calorie malnutrition. The referring physician and medical director was Physician 1. A review of Patient 5's "Physician's Certification for Hospice Benefit" (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 8/13/2021 to 10/11/2021 indicated Physician 1 certified that Patient 5 was still considered to be terminally ill and has a life expectancy of six (6) months or less if the terminal illness runs its normal course. A review of Patient 5's "Interdisciplinary Group (IDG) Conference Note/ Update to Plan of Care" (POC) form, dated 1/17/2022, indicated Hospice Aid (HA) was to visit twice per week. Skilled Nursing (SN) 2x/week. A review of Patient 5's clinical record with the hospice Administrator (ADM) on 2/7/2022 at 2 p.m., indicated Patient 5 had three Interdisciplinary Group (IDG) meetings since admission (8/13/2021). These dates include: 10/8/2021: signed by Registered Nurse 2 (RN2) 1/17/2022: signed by Administrator (ADM) and Physician 1. 1/27/2022: signed by ADM and Physician 1. f. A review of Patient 6's "Face Sheet" form, indicated Patient 6 was admitted to the hospice on 7/30/2020 under routine care, with a primary diagnosis unspecified cirrhosis (disease of the liver) of liver, unspecified severe protein-calorie malnutrition, type 2 Diabetes Mellitus (elevated blood sugar levels), and Dementia (memory loss) in other diseases. The referring physician and medical director was Physician 1. A review of Patient 6's "Physician's Certification for Hospice Benefit" (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 7/30/2020 to 10/27/2020 and 1/21/2022 to 3/21/2022, indicated Physician 1 certified that Patient 6 is considered to be terminally ill and has a life expectancy of six (6) months or less if the terminal illness runs its normal course. A review of Patient 6's "Plan of Care" (POC) form, dated 1/14//2022, indicated Hospice Aid (HA) was to visit twice per week. Skilled Nursing (SN) 1x/week, Medical Social Worker (MSW), Chaplain, and Volunteer were declined on 1/21/2022. A review of Patient 6's medical record with the hospice Administrator (ADM) on 2/7/2022 at 2 p.m., indicated Patient 6 had six Interdisciplinary Group (IDG) meetings in 2021. These dates included: 1/15/2021: signed by Administrator (ADM) and Physician 1. 3/26/2021: signed by ADM and Physician 1. 5/20/2021: signed by ADM and Physician 1. 7/15/2021: signed by ADM and Physician 1. 9/9/2021: signed by ADM and Physician 1. 11/19/2021: signed by ADM During an interview on 2/7/2022 at 2 p.m., with the hospice Administrator (ADM), the ADM stated that IDG meetings are supposed to be held every 14 days. g. A review of Patient 7's "Face Sheet" form, indicated Patient 7 was admitted to the hospice on 6/10/2021 under routine care, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD- group of diseases that cause airflow blockage and breathing-related problems.). The referring physician and medical director was Physician 1. A review of Patient 7's "Physician's Certification for Hospice Benefit" (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 6/10/2021 to 9/7/2021 and 12/7/2021 to 2/4/2022, indicated Physician 1 certified that Patient 7 is still considered to be terminally ill and has a life expectancy of six (6) months or less if the terminal illness runs its normal course. A review of Patient 7's "Plan of Care" (POC) form, dated 12/7/2021, indicated Hospice Aid (HA) was to visit twice per week. Skilled Nursing (SN) 1x/week, MSW evaluation only starting on 12/7/2021. A review of Patient 7's "Recertification Comprehensive Hospice Assessment" dated 12/7/2021, indicated Patient 7 was alert and oriented to person and place, and able to make needs known. It also indicated Patient 7 was receiving routine care, fatigues easily, up as tolerated on wheelchair. In the space Narrative/Summary it indicates MD made aware of the patient current condition. The patient was still eligible for hospice care. A review of Patient 7's medical record with the hospice Administrator (ADM) on 2/7/2022 at 2 p.m. indicated Patient 7 had two Interdisciplinary Group (IDG) meetings in 2021 and one in 2022. These dates include: 9/2/2021: signed by Administrator (ADM) and Medical Social Worker (MSW) 12/7/2021: signed by ADM 1/27/2022: signed by ADM During an interview on 2/7/2022 at 2 p.m. with the hospice Administrator (ADM), the ADM stated that IDG meetings are supposed to be held every 14 days. During a telephone interview on 2/8/2022 at 11:50 a.m. with Physician 2, Physician 2 stated she has been working at hospice facility for, "three years or so". Physician 2 stated that she attends the IDG meetings virtually or via speaker phone. Physician 2 stated that she signs the IDG Meeting through JNCloud (hospice facility computer/electronic program). Physician 2 was not able to recall when she attended the last IDG meeting, "I can't remember, I have to check my agenda". A review of facility's policy and procedure titled "Interdisciplinary Group Meeting" dated April 2017, indicated each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequent than every 15 days or more frequently if the patient's condition requires. A review of facility's policy and procedure titled "Interdisciplinary Group Coordination of Care" dated April 2017 indicated the interdisciplinary group (in collaboration with the attending physician, if any) will conduct assessments, develop and update the plan of care, and review the effectiveness of care a minimum of every two (2) weeks. h. A review of Patient 9's clinical record indicated a start of care date of 12/08/21, with primary diagnosis of 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 9's clinical record indicated the IDG/POC Conference were conducted on 12/08/2021 and 1/13/2022. There was no documented evidence the IDG/POC meeting was conducted between 12/08/21 to 1/13/22. Also, there was no documented evidence IDG/POC meetings were conducted after 1/13/2022 until 2/3/2022. i. A review of Patient 10's clinical record indicated a start of care date of 10/25/21, with primary diagnosis of 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 10's clinical record indicated the IDG/POC Conference were conducted on 10/25/21 and 1/13/22. There was no documented evidence the IDG/POC meeting was conducted between 10/25/21 to 1/13/22. j. A review of Patient 11's clinical record indicated a start of care date of 6/22/21, with primary diagnosis of senile degeneration of brain (the mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age) and unspecified severe protein-calorie malnutrition. A review of Patient 11's clinical record indicated the IDG/POC Conference were conducted on 6/22/21, 9/14/21, 12/19/21 and 1/13/22. There was no documented evidence the IDG/POC meeting was conducted between 6/22/21 to 9/14/21, 9/14/21 to 12/19/21, and 12/19/21 to 1/13/22. Also, there was no documented evidence IDG/POC meetings were conducted after 1/13/2021 until 2/3/2022. On 2/8/2022, at 10:15 a.m., during an interview with the Administrator/Director of Nursing (ADM), the ADM was not able to provide documented evidence the IDG/POC meetings were conducted every 15 days for Patient 9, 10, and 11 during the above period.

Based on interview and record review the facility failed to provide spiritual counseling in accordance to the patient/family's desires for 11 of 11 patients (Patients 1, 2, 3, 4, 5 ,6, 7, 8, 9, 10, and 11). This failure has the potential for the patients/family's spiritual needs will not be met. Findings: An interview on 2/8/2022 at 3:40 p.m. with Administrator (ADM), ADM stated, "We do have a Chaplain, but he is not actively seeing patients right now". ADM was asked for how long has the Chaplain not seen patients. There was no documented evidence it was offered to the hospice patients. A review of facility's policy titled, "Spiritual Assessment" dated April 2017, indicated the purpose of a spiritual assessment was, "To provide guidance for the assessment and reassessment of the spiritual needs of patients and family/caregivers. An in-depth spiritual assessment will be completed for each patient/family by the Hospice Chaplain ... The Hospice Chaplain will contact the patient/family by a home visit or by telephone based on the patient's and family's needs and acceptance of these services."

Based on observation, interview and record review, the hospice facility failed to ensure the Condition of Participation for Medical Director or a similarly qualified physician was met by failing to: 1. Review the necessary data or information for each hospice patient necessary to certify or recertify patients to receive hospice Medicare benefits for, and provided written certification that it was anticipated that the patient's life expectancy was 6 months or less if their illnesses ran their normal course for 10 of 11 sampled patients (Patient 1, 2, 3, 4, 5, 6, 7, 9, 10, and 11). (refer to L667) 2. Ensure the medical director or physician/designee reviewed the patient's clinical information prior to the recertification of hospice benefits for three of 11 sampled patients (Patient 1, 2, and 4). (refer to L668) The cumulative effect of these systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Medical Director services to ensure highest quality of care are provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications for 11 of 13 sampled patients, (Patient 2, 3, 4, 5, 6, 7, 8, 10, 11, 12 and 13) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. There was no documented evidence the Medical Director or other hospice physician had reviewed the clinical information that included the patient's history and physicals, laboratory and imaging data, biopsy results, etc., necessary for intial certification of hospice care and services. These deficient practices resulted in the hospice medical director and/or other hospice physicians certified the patients for hospice care, without documentation of clinical evidence to support the terminal illnes diagnoses, and could result in lack and inappropriate care provided to the patients. Findings: a. A review of Patient 2's clinical record indicated a start of care (SOC) date of 7/20/2021, with a primary diagnosis of cerebrovascular disease (a group of conditions, diseases, and disorders that affect the blood vessels and blood supply to the brain). A review of Patient 2's "Physician Certification for Hospice Benefit" for the first 90-day period from 4/4/2020 to 7/2/2020, indicated Patient 2's terminal diagnosis was cerebrovascular disease, unspecified. The Medical Director (MD) indicated Patient 2 had a life expectancy of six months or less if the terminal illness ran its normal course. There was no documented evidence the hospice's MD communicated with the primary physician to certify Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. The space for "Certifying Physician Summary" was left blank. A review of Patient 2's Comprehensive Nursing Assessment, done by the Registered Nurse (RN), dated 4/4/2020, indicated Patient 2 was awake, alert, oriented, had right eye blindness, non-ambulatory, able to transfer from bed to chair, was using a wheelchair, and needed maximum assistance with activities of daily living. Per the Comprehensive Nursing Assessment, Patient 2 had KPS of 40, PPS of 40%, and NYHA (Spell out abbrevation) class IV. The Karnofsky Performance Scale (KPS) is an assessment tool for predicting of length of survival in terminally ill patients. A KPS of 40 indicated Patient 2 was disabled, requiring special care and assistance. The Palliative Performance Score (PPS) is a widely used tool to access a patient's functional performance and to determine progress towards the end of life. A PPS of 40% indicated Patient 2 was unable to do most activities and was mainly in bed. A review of Patient 2's face sheet indicated Patient 2 resided in Residence 1. b. A review of Patient 3's clinical record indicated a start of care (SOC) date of 12/22/2020, with a primary diagnosis of chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's "Physician Certification for Hospice Benefit" for the first 90-day period from 12/22/2020 to 3/21/2021, indicated Patient 2's terminal diagnosis was chronic obstructive pulmonary disease, unspecified. There was no documented evidence the hospice's Medical Director communicated with the primary physician to certify Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 3's undated "LCD Hospice Eligibility Determination" (LCD), indicated Patient 3 was qualified to receive hospice services based on: 1. Severe a chronic lung disease a. Disabling dyspnea at rest as evidenced by: i. poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity (e.g. bed to chair existence, fatigue and cough); b. Progression of end-stage pulmonary disease as evidenced by: iv. Increasing physician home visits (prior to hospice admission). 2. Hypoxia (low oxygen in tissues) b. O2 sat less than or equal to 88% determined either by arterial blood gases or O2 saturation monitors (these values may be obtained from recent hospital records). ________Stopped here 9/22/22-Sonia Richard A review of Patient 3's "Emergency Department Note" from Community Hospital of Huntington Park, dated 10/30/2020, indicated Patient 3's O2 saturation was 98%, lungs were clear to auscultation bilaterally, and there were no rales (an abnormal crackling or rattling sound heard upon auscultation of the chest, caused by disease or congestion of the lungs), wheezes (a whistling or rattling sound in the chest, as a result of obstruction in the air passages), or ronchi (a low-pitched wheezing, snoring, or squeaking sound heard during auscultation of the chest of a person with partial airway obstruction). A review of Patient 3's Comprehensive Nursing Assessment, done by the Registered Nurse (RN), dated 12/22/2020, indicated Patient 3 was awake, alert, oriented to place, time, and person, had mild dyspnea with mild exertion. O2 saturation was 93% on room air. The Comprehensive Nursing Assessment indicated Patient 3 was ambulatory with a cane or walker. During a joint home visit with Licensed Vocational Nurse (LVN) 2 on 9/7/2022 at 11 a.m., Patient 3 was observed awake, alert, and oriented. It was observed Patient 3's oxygen saturation was 96% to 97% on room air. Patient 3 denied shortness of breath. A review of Patient 3's face sheet indicated Patient 3 resided in Residence 1. c. A review of Patient 4's clinical record indicated a start of care (SOC) date of 9/22/2021, with a primary diagnosis of heart disease. A review of Patient 4's "Physician Certification for Hospice Benefit" for the first 90-day period from 9/22/2021 to 12/20/2021, indicated Patient 3's terminal diagnosis was heart disease, unspecified. There was no documented evidence the hospice's Medical Director communicated with the primary physician to certify Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 4's "LCD Hospice Eligibility Determination" (LCD), dated 9/22/2021, indicated Patient 4 was qualified to receive hospice services based on the "yes" answer provided for "1. Untreatable Condition c. Is patient optimally treated for heart disease with diuretics and vasodilators? 2. Does this CHF (Chronic Heart Failure - a chronic condition in which the heart doesn't pump blood as well as it should) or angina (a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart) patient meet the criteria for NYHA (New York Heart Association) Class IV level (Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases). A review of Patient 4's undated "Current Treatment/Medication/DME List "indicated Patient 4 was not on any diuretics or vasodilators. A review of Patient 4's Comprehensive Nursing Assessment, done by the RN, dated 9/22/2021, indicated Patient 4 was awake, alert, oriented to place, time, and person, and had no dyspnea at rest. The same document indicated Patient 4 did not have any cough or labored respiration. During an interview with the Medical Director (MD) of the Hospice Agency (HA) on 9/9/2022 at 12:15 p.m., MD stated he was not the attending physician of the HA's patients. MD stated he looked at a patient's history and physical exam (H&P) and laboratory results. MD stated, "We look at all the information we got in the first 90 days." MD stated LCD assessment was done entirely by a Nurse Practitioner (NP) who worked for him. MD stated he relied on the NP's judgment. MD also stated the NP electronically signed the LCD assessment electronically using his signature. During an interview with Director of Patient Care Services (DPCS) on 9/9/2022 at 3:23 p.m., DPCS stated there was no documented evidence that Patient 3 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, and O2 sat less than or equal to 88%. DPCS also stated there was no documented evidence that Patient 4 had been optimally treated with diuretics and vasodilators or met the criteria for NYHA class IV. On 9/8/2022 at 3:49 p.m., DPCS also stated Residence 1 was an independent living facility. The homeowners of Residence 1 had no medical responsibilities. Individuals who resided there had to be independent, including taking care of themselves and shopping for their own food. During an interview with Case Auditor/Licensed Vocational Nurse (LVN 1) on 9/9/2022 at 1:30 p.m., LVN 1 stated the HA did not have any records on the weight of Patient 2 prior to his admittance to the HA. She stated the MD was the one making the determination they were eligible for hospice. During an interview with the owner of Residence 1 (Homeowner 2) on 9/7/2022 at 4:09 p.m., Homeowner 2 stated Residence 1 was an independent living. Homeowner 2 stated she provided rooms for homeless people who paid her in exchange for a place to stay. During an interview with Licensed Vocational Nurse (LVN) 2 on 9/8/2022 at 12:50 p.m., LVN 2 stated Residence 1 was an independent living facility and there were no caregivers provided. LVN 2 stated, "My patients walk to the grocery store all the time to buy frozen food." d. A review of Patient 5's clinical record indicated, the patient is 46 years old female who started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) vist was once a week and as needed. The Medical Social Worker (MSW) visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. During a joint home visit with RN 1 on 9/7/2022, at 10:20 a.m., Patient 5 was observed walking using a cane from her car (which was parked in front of the house) to her house (back unit of the house). During an interview with RN 1 at the same time, she stated Patient 5 can drive. During an interview with Patient 5 on 9/7/2022, at10:30 a.m., she stated she lives alone at her unit and she could drive her car to the doctor's office, grocery store, and she could go out for eating. She stated she could cook and shower. She stated she had declined the HA service because she could shower herself. When asked whether she had a pulmonary disease, she stated she had "Asthma" not pulmonary disease, and she did not think she would die within 6 months. A review of Patient 5's "Comprehenive Nursing Assessment" dated 12/28/2021 indicated Patient 5 was alert and oriented, had functional limitation of endurance, was ambulatory using a cane, and had steady gait. Patient 5 had mild dyspnea with mild exertion, and requires oxygen at 2 liters per minute as needed. Patient 5 was observed using chest accesory muscle after activity or walking, and the oxygen saturation at room air was 85 percent. The patient took two puffs of her Albuterol HFA 90 mcg oral inhalation, and after few minutes of rest, the patient's oxygen saturation had improved to 90 percent. Patient 5 had dull ache pain on the bilateral lower legs in a scale of 4/10. Diclofenac Sodium 1 % topical 2-4 times per day for pain management, and the pain was managed well ( reasseed pain prior to end the visit and the pain level was 2/10). A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Pulmonary Disease," dated 12/28/2021, indicated the section 1 and 2 should be met. It indicated Patient 5 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, is less than 30 percent of predicted * Increased visits to Emergency Room A review of Patient 5's record indicated there was no documented evidence Patient 5 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity, Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. A review of Patient 5's record indicated there was no documentation supporting the LCD assessment. A review of Patient 5's form titled, "Physician's Certification for Hospice Benefit" (the document that showed a physician certified a patient's eligibility for hospice benefit), from 12/28/2021 to 3/27/2022, indicated, Patient 5's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 5's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". e. A review of Patient 6's clinical record indicated, the patient is 64 years old male who started hospice care on 7/14/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit once per 2 week plus one visit and LVN visit once per week and one visit as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 6's "Comprehenive Nursing Assessment" dated 7/14/2021 indicated Patient 6 was alert and oriented, used a cane for ambulation, bowel and urinary status was continent. Patient 6 had mild dyspnea with mild exertion, and oxygen saturation was 96 percent. The need of Hospice aide, volunteer and community support was check marked as "None". A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 7/14/2021, indicated the section 1 and 2 should be met. It indicated Patient 6 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Increased visits to Emergency Room *Oxygen saturation less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor A review of Patient 6's record indicated there was no documented evidence Patient 6 was poorly responsive or unresponsive to bronchodilators, Increased visits to Emergency Room, and the oxygen saturation rate was less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 6's record indicated there was no documentation supporting the LCD assessment. A review of Patient 6's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 6's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 6's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". f. A review of Patient 7's clinical record indicated, the patient is 60 years old male who started hospice care on 2/8/22, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit two times per 2 weeks plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's "Comprehenive Nursing Assessment" dated 2/28/2022 indicated Patient 7 was alert and oriented, used a cane for ambulation. Patient 7 had mild dyspnea with mild exertion, and oxygen saturation was 97 percent. It indicated "No" for the question of whether the patient was uncomfortable because of pain. The need of Hospice aide, was check marked as "None". The need for the Volunteer or community support was blank. The nurse's narrative indicated Patient 7 was observed with on and off shortness of breath and was on Albuterol 90 mcg/Actuation inhalation Aerosol 90 mcg 1-2 puffs inhaler three times a day as needed for shortness of breath/wheezing. Patient 7 had generalized body pain and was on Norco 10 mg-325 mg one tablet by mouth every 6 hours as needed for pain. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 2/28/2022, indicated the section 1 and 2 should be met. It indicated Patient 7 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure *Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mililimeter Mercury (mmHg). A review of Patient 7's record indicated there was no documented evidence Patient 7 was poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, Hypoxemia (an abnormally low concentration of oxygen in the blood) at rest on room air, as evidenced by pO2 (partial pressure of oxygen - a measure of the tension or pressure of oxygen dissolved in the blood - If a pO2 level is lower than 80 mmHg, it means that a person is not getting enough oxygen) less than or equal to 55 mililimeter mercury (mmHg). A review of Patient 7's record indicated there was no documentation supporting the LCD assessment. A review of Patient 7's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 7's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 7 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 7's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". g. A review of Patient 8's clinical record indicated, the patient is 44 years old male who started hospice care on 1/21/22, with a terminal diagnosis of COPD. It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated the RN visits for initial assessment, supervisory visit, and ongoing comprehensive assessment, reassessment, recertification and as needed. The Skilled Nurse (SN) visit once a week and onece per week as needed. The MSW was to visit within 5 days from the SOC, certification, and as needed. The HA service and the volunteer services were offered and declined. A review of Patient 8's "Comprehenive Nursing Assessment" dated 1/21/2022 indicated Patient 8 was alert and oriented, needed stand by assist for ambulation, Patient 8 had mild dyspnea with mild exertion, and oxygen saturation was 92 percent. Patient 8 was continent in bowel and bladder. The need of Hospice aide, and the need of community support were check marked as "None". The need for the Volunteer was check marked for errands. The nurse's narrative indicated Patient 8 was 43 years old male with last hospitalization on 9/18/2021 to 9/21/2021 for evaluation and treatment of left lower extremity torn ligament. According to the patient, his condition had progressively deteriorated in the past few months, evidence of dyspnea with activity and even at rest. Upon assessment, the patient was sitting in a chair and had a pain level to be 8/10. The patient was placed with medication of norco 10/325 mg one tabletorally every 6 hours as needed for moderate to severe pain and Tylenol 500 mg every 6 hours for breakthrough pain. At the end of the visit and assessment, the patient was noted relaxed without any discomfort, no shortness of breath, and the pain level was 0/10. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 1/21/2022, indicated the section 1 and 2 should be met. It indicated Patient 8 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure * Oxygen saturation less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documented evidence Patient 8 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, Oxygen saturation less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documentation supporting the LCD assessment. A review of Patient 8's form titled, "Physician's Certification for Hospice Benefit" from 1/21/2022 to 4/20/2022, indicated, Patient 8's terminal diagnoses was COPD. It was indicated in the physician's narrative that Patient 8 no longer wants to continue aggressive treatment and stated he wanted comfort measures only. It was indicated in the section of "Certifying Physician Summary" that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 6's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". During an interview with the Director of Patient Care Services (DPCS) on 9/8/2022, at 4:15 p.m., she stated she was not able to find the documented evidence Patient 5, 6, 7, 8, 9, were poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity, Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patients' primary physicians that Patient 5, 6, 7, 8, 9 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". On 9/9/2022 at 12:15 p.m., a telephone interview was conducted with the Medical Director of the agency. When asked whether he had his primary patient at the agency, he stated he had a lot of patients and he was not sure/recall. And then, he stated he was not a primary physician for all of the agency's patients. He stated he decides eligibility of hospice care based on signs/symptoms, diagnoses (including history and Physical, labs), ADLs, stability, bed bound status and frequency of hospitalization, and LCD assessment. He stated the Nurse Practitioner (NP) who had been working for him was supposed to review all the assessments including the History and Physical. He stated he had not actually reviewed the patients' History and Physical, and LCD Assessment. Instead, he relied on NP's judgement. When informed that there was no documentation supporting the LCD assessment and the patient's diagnoses, the medical director stated he did not know that. He stated NP 1, who had been working for him for 4-5 months, had been signed his signature electronically in the "Physician's Certification for Hospice Benefit" behalf of him. He stated he had another NP worked for him before NP 1, and he always had a NP worked for him. He stated he did not have any supportive documentation for the hospice eligibility assessment, and had not communicated with the patients' attending physician. He stated he should have overseen things like eligibility of patients for the hospice service. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). A review of the agency's undated Policy and Procedure titled "Certification of Terminal Illness" indicated the clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. According to the LCD, the physician must briefly synthesize the clinical information supporting the terminal diagnosis, and attest that they composed the narrative after reviewing the clinical information and where applicable, examining the patient. A review of the agency's job description summary titled "Hospice Medical Director" revised April 2017 indicated the duties and responsibilities of the Medical Director will include, but not limited to, the following: * Reviewing patients'medical eligibility for hospice services, in accordance with the dhospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness * Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. * Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. *Providing written certification of the terminal illness for all subsequent benefit periods. e. A review of Patient 5's "Face Sheet" form, indicated Patient 5 was admitted to the hospice on 8/13/2021 under routine care, with a primary diagnosis senile degeneration of brain (memory loss) and moderate protein-calorie malnutrition. The referring physician and medical director was Physician 1. A review of Patient 5's "Physician's Certification for Hospice Benefit" (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 8/13/2021 to 10/11/2021 indicated Physician 1 certified that Patient 5 was still considered to be terminally ill and had a life expectancy of six (6) months or less if the terminal illness runs its normal course. A review of Patient 5's "Interdisciplinary Group (IDG) Conference Note/ Update to Plan of Care" (POC) form, dated 1/17//2022, indicated Hospice Aid (HA) was to visit twice per week. Skilled Nursing (SN) 2x/week. A review of Patient 5's "Comprehensive Hospice Assessment" dated 8/13/2021 indicated Patient 5's Karnofsky Performance Status Scale (KPSS - functional impairment scale) was at 40% (disabled, requires special care and assistance. Unable to care for self; requires equivalent of institutional or hospital care; disease may be progressing rapidly). Patient 5's Palliative Performance Scale (PPS - assesses functional performance and determines progression toward end of life) was at 40% (mainly in bed, unable to do most activity extensive disease, mainly assistance, normal or reduce intake, full or drowsy, confusion conscious level). Weight measured at 112 lbs. A review of Patient 5's "Recertification Comprehensive Hospice Assessment" dated 12/3/2021 2021 indicated Patient 5's Karnofsky Performance Status Scale was at 40%. Patient 5's Palliative Performance Scale was at 40%. Weight measured at 115 lbs. A review of Patient 5's "MD Notes" dated 8/13/2021, indicated weight loss of 10 lbs. (pounds) in 3 months. There was no other verified clinical information necessary for patient's hospice certification in the clinical record. f. A review of Patient 6's "Face Sheet" form, indicated Patient 6 was admitted to the hospice agency on 7/30/2020 under routine care, with a primary diagnosis unspecified cirrhosis (disease of the liver) of liver, unspecified severe protein-calorie malnutrition, type 2 Diabetes Mellitus (elevated blood sugar levels), and Dementia (memory loss) in other diseases. The referring physician and medical director was Physician 1. A review of Patient 6's "Physician's Certification for Hospice Benefit" (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 7/30/2020 to 10/27/2020 and 1/21/2022 to 3/21/2022, indicated Physician 1 certified that Patient 6 is considered to be terminally ill and has a life expectancy of six (6) months or less if the terminal illness runs its normal course. A review of Patient 6's "Plan of Care" (POC) form, dated 1/14//2022, indicated Hospice Aid (HA) was to visit twice per week. Skilled Nursing (SN) 1x/week, Medical Social Worker (MSW), Chaplain, and Volunteer were declined on 1/21/2022. A review of Patient 6's "Recertification Comprehensive Hospice Assessment" dated 1/14/2022, in the space Narrative/Summary it indicated Patient 6 is eligible for hospice care based on LCD guidelines. There was no documented evidence of other verified clinical information necessary for patient's hospice certification in the clinical record. g. A review of Patient 7's "Face Sheet" form, indicated Patient 7 was admitted to the hospice agency on 6/10/2021 under routine care, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD- group of diseases that cause airflow blockage and breathing-related problems.). The referring physician and medical director was Physician 1. A review of Patient 7's "Physician's Certification for Hospice Benefit" (CTI - document that showed a physician certified a patient's eligibility for hospice benefits), dated 6/10/2021 to 9/7/2021 and 12/7/2021 to 2/4/2022, indicated Physician 1 certified that Patient 7 is still considered to be terminally ill and has a life expectancy of six (6) months or less if the terminal illness runs its normal course. A review of Patient 7's "Plan of Care" (POC) form, dated 12/7/2021, indicated Hospice Aid (HA) was to visit twice per week. Skilled Nursing (SN) 1x/week, MSW evaluation only starting on 12/7/2021. A review of Patient 7's "Comprehensive Hospice Assessment" dated 6/10/2021, indicated Patient 7 was alert and oriented to person and place, and able to make needs known. It also indicated Patient 7 was receiving routine care, fatigues easily, up as tolerated on wheelchair, lives alone. Weight recorded at 240 lbs. Respiratory status is dyspnea at rest, uses oxygen at 2-4 liters, and the severity of symptoms are moderate. In the space Narrative/Summary it indicated, due to progressive decline in condition patient requested hospice care at home for comfort measures and symptoms management. A review of Patient 7's "Recertification Comprehensive Hospice Assessment" dated 12/7/2021, indicated Patient 7 was alert and oriented to person and place, and able to make needs known. It also indicated Patient 7 was receiving routine care, fatigues easily, up as tolerated on wheelchair, lives alone. No weight recorded. Respiratory status is unlabored, uses oxygen at 2-4 liters per minutes via nasal canula as needed, and the severity of symptoms are moderate. In the space Narrative/Summary it indicates MD made aware of the patient current condition. The patient is still eligible for hospice care. There was no documented evidence of other verified clinical information necessary for patient's hospice certification in the clinical record. A review of Patient 7's "MD Notes" dated 6/10/2021 indicated New York Heart Association IV (NYHA IV - Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases.) During an interview on 2/8/2022 at 11:35 a.m. with the hospice Administrator (ADM), the ADM stated, "I've never encountered an LCD guideline paper. JNCloud (server used for their electronic charting) just recently placed the form in the system, but we have not implemented it yet. ADM stated the narrative portion in the comprehensive hospice is their History and Physical (H&P). During a telephone interview on 2/8/2022 at 11:50 a.m. with Physician 2, Physician 2 stated she has been working at hospice facility for, "three years or so". Physician 2 stated the hospice admission process is, "They will get a History and Physical (H&P), somebody will assess the patient, they ask me if they are qualified based on my assessment and H&P review and a discussion with their primary". Physician 2 stated that the LCD responses are based on, "depending on their symptoms and objective finding and medical history. We do use an LCD assessment. I usually fax it to them, the hospice office". Physician 2 stated that the CTI responses are based on, "Kind of concur with the nurse if they are declining or not. We communicate verbally or face time with the nurse, that's how we communicate". Physician 2 stated that patients are assigned to her because their primary doctor "does not want to follow them". During an interview on 2/8/2022 at 3:40 p.m. with ADM, ADM provided "MD Notes". ADM stated, "the "MD Notes" are the face to face the doctor does with the nurse. Sometimes the patient does not come with an H&P, so the doctor does this. This is what she was talking about when she said she faxes it over to us (referring to Physician 2)". A review of facility's policy and procedure titled, "Admission Criteria and Process" dated April 2017 indicated "The patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). h. A review of Patient 10's admission record indicated the patient was admitted to the HA on 1/07/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Patient 10's admission information sheet (face sheet) indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated skilled nurse (SN) visits once per week and once per week as needed and change of condition for assessment and comfort monitoring, the spiritual counselor (SC) and medical social worker (MSW) to do assessment within 5 days from SOC (start of care), certification & as needed. The hospice aide (HA) and volunteer visit were declined. A review of the "Physician's Certification for Hospice Benefit (the patient must be certified as being terminally ill to receive hospice care)" from 1/07/2022 to 4/06/2022, signed by the Medical Director who was also the referring doctor, indicated "It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice". It also indicated Patient 10 meets LCD (Local Coverage Determination-determining Terminal Status) medical guidelines to receive hospice services. A review of the form "LCD Hospice Eligibility Determination" of Pulmonary Disease dated 7/05/2022, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 10 had a disabling dyspnea (shortness of breath) at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat (Oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95-100%) less than or equal to 88% determined by O2 sat monitors. A review of Patient 10's clinical record indicated there was no documented evidence Patient 10 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators and/or had O2 saturation of 88% or less. A review of Patient 10's Comprehensive Nursing Assessment, dated 1/07/2022, indicated Patient 10 was awake, alert, oriented and verbally responsive. Patient 10 was ambulatory with steady gait and able to perform ADLs (or activities of daily living, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) independently. Patient 10's oxygen saturation was 92% in room air and has regular heart sounds. The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." On 9/07/2022, at 11:25 a.m., a joint home visit was made for Patient 10 with the Registered Nurse (RN 1) at the patient's residence. Patient 10 was not at home. Several phone calls were made to Patient 10's three phone number listed on her clinical records, but calls have either no dial tone and/or went straight to voicemail. At 11:35 a.m., during an interview, RN 1 stated she does not know where Patient 1 was located. i. A review of Patient 11's admission record indicated the patient was admitted to the HA on 10/17/2021, with diagnosis of heart disease, unspecified (a type of disease that affects the heart or blood vessels). Patient 11's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated the registered nurse visit once every 2 weeks and as needed, and the licensed vocational nurse visit of once a week and one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of the "Physician's Certification for Hospice Benefit" signed by the Medical Director who was also the referring doctor, indicated Patient 11 has a life expectancy of six months or less, if the terminal illness runs its normal course. It also indicated Patient 11 meets LCD medical guidelines to receive hospice service. A review of the form "LCD Hospice Eligibility Determination" of Heart Disease dated 10/31/202, indicated section 1 - "Untreatable Condition", and section 2 - New York Heart Association (NYHA) Classification" must be met. It was mark "yes" in section 1 that Patient 11 has been ruled out as a candidate for surgical procedure. Section 2 was mark "yes" that Patient 11 met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). A review of Patient 11s clinical record indicated no documented evidence Patient 11 was ruled out as a candidate for surgical procedure related to heart disease. There was no documented evidence Patient 11 was on complete rest, confined to bed and chair, any physical activity brings on discomfort and symptoms occurs at rest. A review of Patient 11's "Comprehensive Nursing Assessment", dated 10/17/2021, indicated Patient 11 was alert and oriented x 4 (person, place, time, and event). Patient 11 was ambulatory with limping gait using a walker, and able to perform ADLs with minimal or moderate assistance. Patient 11's heart rate was irregular, at 93 beats per minute, oxygen saturation was 96% in room air and no edema was observed. Patient 11's NYHA documented classification was IV (New York Heart Association Class IV - patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." During a phone interview with Patient 11, on 9/12/2022 at 10:30 a.m., Patient 11 stated he was not aware of any surgical procedure about his heart, and he was doing okay. He stated he has mild symptoms when he went out for a walk but has no symptoms if he was in bed or chair. Patient 11 stated nobody told him that he has life expectancy of 6 months or less. j. A review of patient 12's admission record indicated the patient was admitted to the HA on 6/27/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Patient 12's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 12's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated skilled nurse (SN) visits once per week and one as needed. The hospice aide (HA), MSW, SC, and volunteer service were declined. A review of the "Physician's Certification for Hospice Benefit" from 6/27/2022 to 9/24/2022, signed by the Medical Director who was also the referring doctor, indicated "It is my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice". It also indicated Patient 12 meets LCD medical guideline criteria to receive hospice care/services. A review of the form of "LCD Hospice Eligibility Determination" of Pulmonary Disease dated 6/27/2022, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 12 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat less than or equal to 88% determined by O2 sat monitors. A review of Patient 12's clinical record indicated there was no documented evidence Patient 12 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators and had O2 saturation of 88% or less. A review of Patient 12's "Comprehensive Nursing Assessment", dated 6/27/2022, indicated Patient 12 was awake, alert, oriented (to person, place, time) and can answer appropriately to questions asked. Patient 12 was ambulatory using a cane or walker and noted with unsteady gait and able to perform ADLs with minimal or moderate assistance. Patient 12's oxygen saturation was 89% in room air. The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." On 9/08/2022, at 2:55 p.m., a home visit was conducted for Patient 12. Patient 12 was observed awake, alert, ambulatory, not on oxygen and not showing any signs and symptoms of pulmonary disease. Patient 12 stated he walks to the market everyday several blocks from where he lives and does not have shortness of breath. Patient 12 stated he was diagnosed with COPD since 2010, takes his medication/inhalers daily and is not going to die within 6 months. k. A review of Patient 13's admission record indicated the patient was admitted to the HA on 6/28/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 13's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated RN visits once every two weeks plus one visit as needed, and LVN visit once a week plus one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of the "Physician's Certification for Hospice Benefit" from 6/28/2022 to 9/25/2022, signed by the Medical Director who was also the referring doctor, indicated "It is my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice". It also indicated Patient 13 has increased episodes of shortness of breath mostly relieved with rest. A review of the form of "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" of Pulmonary Disease, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 13 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat less than or equal to 88% determined by O2 sat monitors. A review of Patient 13's clinical record indicated there was no documented evidence Patient 13 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators and had O2 saturation of 88% or less. A review of Patient 13's "Comprehensive Nursing Assessment", dated 6/28/2022, indicated Patient 13 was awake, alert, oriented (to person, place, time), verbally responsive and can express needs and discomfort. Patient 13 was ambulatory with unsteady gait and noted with shortness of breath with moderate exertion that was relieved with rest and inhaler. Patient 13's oxygen saturation was 92% in room air. The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." On 9/9/2022 at 12:15 p.m., a telephone interview was conducted with the Medical Director of the agency. When asked whether he had his primary patient at the agency, he stated he had a lot of patients and he was not sure/recall. And then, he stated he was not a primary physician for all of the agency's patients. He stated he decides eligibility of hospice care based on signs/symptoms, diagnoses (including history and Physical, labs), ADLs, stability, bed bound status and frequency of hospitalization, and LCD assessment. He stated the Nurse Practitioner (NP) who had been working for him was supposed to review all the assessments including the History and Physical. He stated he had not actually reviewed the patients' History and Physical, and LCD Assessment. Instead, he relied on NP's judgement. When informed that there was no documentation supporting the LCD assessment and the patient's diagnoses, the medical director stated he did not know that. He stated NP 1, who had been working for him for 4-5 months, had been signed his signature electronically in the "Physician's Certification for Hospice Benefit" behalf of him. He stated he had another NP worked for him before NP 1, and he always had a NP worked for him. He stated he did not have any supportive documentation for the hospice eligibility assessment and had not communicated with the patients' attending physician. He stated he should have overseen things like eligibility of patients for the hospice service. During an interview with the Director of Patient Care Services (DPCS) on 9/12/2022 at 2:35 p.m., she stated she was not able to find the documented evidence Patient 10, 11, 12 and 13, were poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity, or had increased visits to Emergency Room, or had disabling dyspnea and oxygen saturation 88% and below, or patients been ruled out for a surgical procedure. A review of the agency's job description summary titled "Hospice Medical Director" revised April 2017 indicated the duties and responsibilities of the Medical Director will include, but not limited to, the following: * Reviewing patients' medical eligibility for hospice services, in accordance with the hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness * Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. * Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. *Providing written certification of the terminal illness for all subsequent benefit periods.

Based on observation, interview and record review, the agency failed to ensure the hospice services were provided by a physician who reviewed the patient's clinical information prior to approving another 60 days of hospice service to obtain justification for continuing hospice services for nine out of 13 sampled patients (Patient 2, 3, 4, 5, 6, 7, 8, 10 and 11). This deficient practice result in providing hospice care to a patient who did not meet readmission criteria and did not qualify for the Medicare hospice benefit. Findings: d. A review of Patient 5's clinical record indicated, Patient 5 was 46 years female, started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. During a joint home visit with RN 1 on 9/7/2022, at 10:20 a.m., Patient 5 was observed walking with using a cane from her car (which was parked in front of the house) to her house (back unit of the house). During an interview with RN 1 at the same time, she stated Patient 5 can drive. During an interview with Patient 5 on 9/7/2022, at10:30 a.m., she stated she lives alone at her unit and she could drive her car to the doctor's office, grocery store, and she could go out for eating. She stated she could cook and shower. She stated she had declined the HA service because she could shower herself. When asked whether she had a pulmonary disease, she stated she had "Asthma" not pulmonary disease, and she did not think she would die within 6 months. A review of Patient 5's "Comprehenive Nursing Assessment" dated 6/24/2022 indicated Patient 5 was alert and oriented, had functional limitation of endurance, was ambulatory using a cane. A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Pulmonary Disease," dated 3/27/2022, 6/24/2022, indicated Patient 5 was assessed as "yes" with followings: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, is less than 30 percent of predicted * Increased visits to Emergency Room *Oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitors A review of Patient 5's record indicated there was no documented evidence Patient 5 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity, Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room, and Oxygen saturation rate was less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitors. A review of Patient 6's record indicated there was no documentation supporting the LCD assessment. A review of Patient 5's form titled, "Physician's Certification for Hospice Benefit" (the document that showed a physician certified a patient's eligibility for hospice benefit), from 3/28/2022 to 6/25/2022, and from 6/26/2022 to 8/24/2022 indicated Patient 5's terminal diagnoses was COPD, and Patient 5 meets LCD Medical guide lines to receive hospice service. It was indicated Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 5's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". e. A review of Patient 6's clinical record indicated, the patient started hospice care on 7/14/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit once per 2 weeks plus one visit and LVN visit once per week and one visit as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 6's "Comprehenive Nursing Assessment" dated 8/4/2022 indicated Patient 6 was alert and oriented, needed stand by assist, used a cane for ambulation. Patient 6 had mild dyspnea with mild exertion, and oxygen saturation was 96 percent. The section whether the patient was uncomfortable because of pain indicated "No". The need of Hospice aide, volunteer and community support was check marked as "None". A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 9/1/2022, indicated the section 1 and 2 should be met. It indicated Patient 6 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Hospitalization for pulmonary infections *Oxygen saturation less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 6's record indicated there was no documented evidence Patient 6 was poorly responsive or unresponsive to bronchodilators, hospitalization for pulmonary infections, and the oxygen saturation rate was less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 6's record indicated there was no documentation supporting the LCD assessment. A review of Patient 6's form titled, "Physician's Certification for Hospice Benefit" from 9/7/2022 to 11/5/2021, indicated, Patient 6's terminal diagnoses was COPD. The "Certifying Physician Summary" indicated Patient 6 met the LCD Medical Guidelines to receive the hospice service, and Patient 6 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course", while there was no documentation supporting the LCD assessment. A review of Patient 6's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". f. A review of Patient 7's clinical record indicated, the patient started hospice care on 2/8/22, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit two times per 2 weeks plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's "Comprehenive Nursing Assessment" dated 5/3/2022 indicated Patient 7 was alert and oriented, used a cane for ambulation. The section whether the patient was uncomfortable because of pain indicated "No". The spaces for the vital signs (blood pressure, pulse, temperature) and oxygen saturation was blank. It indicated the patient did not have dyspnea. It indicated "No" for the question of whether the patient was uncomfortable because of pain. The need of Hospice aide, Volunteer, and community support was check marked as "None". The nurse's narrative indicated Patient 7 was 60 year old male, recertified via telehealth. Per primary caregiver (PCG), Patient 7 did not have shortness of breath, but complained of generalized pain with the pain pain level 2/10 on a pain scale. PCG was instructed to give Norco 10 mg-325 mg one tablet every 6 hours as needed. When rechecked, the pain level was 1/10 on a pain scale. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 5/3/2022, indicated the section 1 and 2 should be met. It indicated Patient 7 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure *Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mililimeter Mercury (mmHg). However, a review of Patient 7's record indicated there was no documented evidence Patient 7 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, Hypoxemia (an abnormally low concentration of oxygen in the blood) at rest on room air, as evidenced by pO2 (partial pressure of oxygen - a measure of the tension or pressure of oxygen dissolved in the blood - If a pO2 level is lower than 80 mmHg, it means that a person is not getting enough oxygen) less than or equal to 55 mililimeter mercury (mmHg). A review of Patient 7's record indicated there was no documentation supporting the LCD assessment. A review of Patient 7's form titled, "Physician's Certification for Hospice Benefit" from 5/9/2022 to 8/6/2022, indicated, Patient 7's terminal diagnoses was COPD. The "Certifying Physician Summary" indicated Patient 6 met LCD Medical Guidelines to receive the hospice service, and Patient 6 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 7's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". A review of Patient 7's record indicated there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's other physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". g. A review of Patient 8's clinical record indicated, the patient started hospice care on 1/21/22, with a terminal diagnosis of COPD. It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated the RN visits for initial assessment, supervisory visit, and ongoing comprehensive assessment, reassessment, recertification and as needed. The Skilled Nurse (SN) visit once a week and onece per week as needed. The MSW was to visit within 5 days from the SOC, Certification and as needed. The HA service and the volunteer services were offered and declined. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 7/8/2022, indicated the section 1 and 2 should be met. It indicated Patient 8 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure * Oxygen saturation less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documented evidence Patient 8 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, Oxygen saturation less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documentation supporting the LCD assessment. A review of Patient 8's form titled, "Physician's Certification for Hospice Benefit" from 7/20/2022 to 9/17/2022, indicated, Patient 8's terminal diagnoses was COPD. It was indicated in the RN Prognosis Summary that Patient 8 was 43 years old, ambulatory usines cane, had pain on left ankle with pain level 8/10, and takes Norco 10/325 mg one tablet every 6 hours as needed for moderate to severe pain. When reassessed the pain level at the end of the visit, the pain was 0/10. Patient 8 was continent with both urinary and bowel functions, and the patient did not have respiratory distress. It was indicated in the section of "Certifying Physician Summary" that Patient 8 meets LCD Medical Guidelines to receive ospice service, the patient was appropriate to remain and receive hospice care with a terminal prognosis of 6 months or less if disease process follows its normal course. A review of Patient 8's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". During an interview with the Director of Patient Care Services (DPCS) on 9/8/2022, at 4:15 p.m., she stated she was not able to find the documented evidence Patient 5, 6, 7, 8, , were poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity, Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. The DPCS was not able to provide the documentation supporting the LCD assessment of Patient 5, 6, 7, 8, on above days. Also, the DPCS was not able to provide the documented evidence that the hospice medical director or the hospice attending physician communicated, with the patients' primary physicians to verify Patient 5, 6, 7, 8, had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". On 9/9/2022 at 12:15 p.m., a telephone interview was conducted with the Medical Director of the agency. When asked whether he had his primary patient at the agency, he stated he had a lot of patients and he was not sure/recall. And then, he stated he was not a primary physician for all of the agency's patients. He stated he decides eligibility of hospice care based on signs/symptoms, diagnoses (including history and Physical, labs), ADLs, stability, bed bound status and frequency of hospitalization, and LCD assessment. He stated the Nurse Practitioner (NP) who had been working for him was supposed to review all the assessment and documentation including the History and Physical. He stated he had not actually reviewed the patients' clinical documentation and LCD Assessment. instead, he relied on NP's judgement. When informed the Medical director that there was no documentation supporting the LCD assessment and the patient's diagnoses, he stated he did not know that. He stated NP 1, who had been working for him for 4-5 months, had been signed his signature electronically in the "Physician's Certification for Hospice Benefit" behalf of him. He stated he had another NP worked for him before NP 1, and he always had a NP work for him. He stated he did not have any supportive documentation for the hospice eligibility assessment, and had not communicated with the patients' attending physician. He stated he should have overseen things like eligibility of patients for the hospice service. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). A review of the agency's undated Policy and Procedure titled "Certification of Terminal Illness" indicated the clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. According to the LCD, the physician must briefly synthesize the clinical information supporting the terminal diagnosis, and attest that they composed the narrative after reviewing the clinical information and where applicable, examining the patient. A review of the agency's job description summary titled "Hospice Medical Director" revised April 2017 indicated the duties and responsibilities of the Medical Director will include, but not limited to, the following: * Reviewing patients'medical eligibility for hospice services, in accordance with the dhospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness * Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. * Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. *Providing written certification of the terminal illness for all subsequent benefit periods.

Based on interview and record review the facility failed to conduct criminal background checks for 10 out of 11 employee files reviewed (Employees 1-10). This failure had the potential to affect the health and safety of the patients. Findings: A concurrent interview and record review on 2/7/2022 at 1:20 p.m., with Administrator (ADM) of 11 employee records indicated 10 employee records were missing their criminal background checks. ADM stated, Case Manager (CM) "handles the employee records, he is sick. I will call him and ask where he has them". An interview on 2/7/2022 at 2 p.m., with ADM, ADM stated CM "is no longer with us, he comes on and off. His last day was October 8th, but we asked him to stay over but he was not consistent on being here. I have a lot of things to do. We just hired someone, (RN 1), and she will begin on March 1st". An interview on 2/8/2022 at 3:40 p.m. with ADM, ADM was asked if the employee criminal background records were found. ADM stated, "No, I couldn't find it."