Every finding on record at Auxilium Palliative Hospice Care, Inc.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Conditions of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) regarding Patient’s Rights was met as follows: --- 1. The HA failed to provide two of fourteen sampled patients (Patient 1 and Patient 2) information regarding their rights as a hospice patient in a language that would be understood and preferred by the patient. This failure resulted in the patient not fully understanding or knowing their rights as a hospice patient. (Refer to L502). 2. The HA failed to ensure that three of fourteen sampled patients (Patient 1, Patient 2, and Patient 8) always had access to their plans of care (POC, a personalized, comprehensive document that outlines the medical, emotional, psychosocial, and spiritual needs of a patient and their family during hospice care). This deficient practice had the potential to result in the patient and/or patient family/caregiver being unable to be an active participant in his or her care. (Refer to L513). 3. The HA failed to inform five of fourteen sampled patients (Patient 1, Patient 2, Patient 8, Patient 9, and Patient 11) about the services the HA provided and the limitations of these services. This deficient practice resulted in Patient 1, Patient 2, Patient 8, Patient 9, and Patient 11 not to be informed about the purpose of the hospice care services. (Refer to L519). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (decided and controlled by law) mandated compliance with Federal regulation for Patients' Rights to ensure their rights are not violated and receive the highest quality of hospice care.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to provide two of fourteen sampled patients (Patient 1 and Patient 2) information regarding their rights as hospice patients in a language the patients understood. This deficient practice resulted in patients not understanding the HA’s care and services, available for the patients and their family, and patients being unable to exercise their rights to decline the hospice services. --- a. During a review of Patient 1’s Personal Information indicated Patient 1 was admitted to the HA on 10/1/2024 with diagnoses that included atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) without angina pectoris (chest pain caused by reduced blood flow to the heart muscle) and type 2 diabetes mellitus (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to elevated blood sugar levels).During a review of the Hospice Admission Service Agreement and Release of Information and Consent to Treatment for Patient 1, it was noted both forms were written in English and signed by Patient 1 on 10/1/2024. During a joint home visit at Patient 1’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 11:20 a.m., Patient 1 was observed awake, alert, and oriented to person, place, and time (aware of his own identity, current location, and the current date and time). Patient 1 was observed walking independently without assistive device. Patient 1 was Spanish speaking. b. During a review of Patient 2’s Personal Information indicated Patient 2 was admitted to the HA on 10/1/2024 with diagnoses that included acute on chronic combined systolic and diastolic heart failure (a condition where a patient with previously stable, chronic heart failure experiences a sudden worsening of symptoms, due to both systolic [pumping] and diastolic [filling] dysfunction) and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure.During a review of the Hospice Admission Service Agreement and Release of Information and Consent to Treatment for Patient 2, it was noted that both forms were written in English and signed by Patient 2 on 10/1/2024. During a joint home visit at Patient 2’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 12:10 p.m., Patient 2 was observed awake, alert, and oriented to person, place, and time. Patient 2 is the wife of Patient 1. Patient 2 was Spanish speaking.During an interview with Patient 1 and Patient 2 in their native language (Spanish) on 6/25/2025, at 12:48 p.m., Patient 1 and Patient 2 stated they remembered signing some papers when they were first visited by the hospice nurse. Patient 2 stated she was not sure what the papers said, but she and her husband (Patient 1) signed them as instructed by the nurse. Patient 1 and Patient 2 stated they were not provided with a copy of the papers they signed.During an interview with the Director of Patient Care Services (DPCS) on 6/27/2025, at 12:45 p.m., the DPCS stated the HA had a Spanish version of the Hospice Admission Service Agreement and Release of Information and Consent to Treatment. The DPCS did not elaborate why the HA used the English (a language the patients did not understand) version for Patient 1 and Patient 2. During a review of the HA’s policy and procedure (P & P), titled “Patient Bill of Rights,” revised June 2019, the P & P indicated that hospice would make reasonable efforts to have written copies of the notice of rights and responsibilities available in the languages commonly spoken in hospice’s service area.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure three of fourteen sampled patients (Patient 1, Patient 2, and Patient 8) had access to their plans of care at all times. This deficient practice had the potential to result in patient and/or their family member/caregiver unable to be an active participant in his/her care. --- a. During a review of Patient 1’s Personal Information indicated Patient 1 was admitted to the HA on 10/1/2024 with diagnoses that included atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) without angina pectoris (chest pain caused by reduced blood flow to the heart muscle) and type 2 diabetes mellitus (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to elevated blood sugar levels).During a review of Patient 1’s electronic health record on 6/24/2025, there was no individualized plan of care developed for Patient 1 for the current certification period, effective from 5/29/2025 to 7/27/2025.During a joint home visit at Patient 1’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 11:20 a.m., Patient 1 was observed awake, alert, and oriented to person, place, and time (aware of his own identity, current location, and the current date and time). Patient 1 was also observed walking independently without assistive device. Patient 1 was Spanish speaking.  Patient 1’s home folder was requested to be reviewed. LVN 1 stated Patient 1 told her he did not have it when she visited Patient 1 yesterday.  b. During a review of Patient 2’s Personal Information indicated Patient 2 was admitted to the HA on 10/1/2024 with diagnoses that included acute on chronic combined systolic and diastolic heart failure (a condition where a patient with previously stable, chronic heart failure experiences a sudden worsening of symptoms, due to both systolic [pumping] and diastolic [filling] dysfunction) and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure. During a review of Patient 2’s electronic health record on 6/24/2025, there was no individualized plan of care developed for Patient 2 for the current certification period, effective from 5/29/2025 to 7/27/2025.During a joint home visit at Patient 2’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 12:10 p.m., Patient 2 was observed awake, alert, and oriented to person, place, and time. Patient 2 is the wife of Patient 1. Patient 2 was Spanish speaking. Patient 2’s home folder was requested to be reviewed. LVN 1 stated Patient 2 told her she did not have it when she visited Patient 2 yesterday. During an interview with Patient 1 and Patient 2 in their native language (Spanish) on 6/25/2025, at 11:42 a.m., they both stated they were never provided with home folders by the HA. Patient 1 stated he had never received a copy of the care plan or medication list. Patient 2 confirmed what Patient 1 said. During an interview with LVN 1 on 6/25/2025 at 12:12 p.m., LVN 1 stated that usually the HA would provide patients with a home folder that had emergency phone numbers, a copy of signed consents, a copy of care plan, and a copy of medication profile. LVN 1 stated it was necessary that the patients had the care plan and medication profile so they were aware of what the goal was for them and if there was any problem, it could be added to the care plan.During an interview with the Director of Patient Care Services (DPCS) on 12/26/2025, at 12:45 p.m., the DPCS stated it was important to provide patients with the plan of care and medication profile. The DPCS stated if the visiting nurse saw the patient did not have it, the nurse would need to let the office know so the patients could be supplied with one.  c. During a review of Patient 8’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 8’s start of care (SOC) date of 2/3/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery (blood vessels that supply blood to the heart muscle) without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 8’s clinical record titled, POC Summary indicated an order dated 2/3/2025, for the skilled nurse (SN) to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the registered nurse (RN) to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.   During a joint home visit at Patient 8’s residence, on 6/25/2025, at 11 a.m., with LVN 2, Patient 8 was observed awake, alert, oriented x 3 (to person, place, and time), ambulatory using a cane, and was independent of her care. During a review of Patient 8’s hospice folder located at the patient’s home, on 6/25/2025 at 11:40 a.m., a copy of the patient’s current POC could not be found. During a concurrent interview, Patient 8 stated she was not provided with a copy of her current plan of care and does not know what it looks like.During an interview with the Administrator/Director of Patient Care Services (ADM/DPCS), on 6/26/2025 at 10:52 a.m., the ADM/DPCS stated that she was aware that Patient 1, Patient 2, and Patient 8 did not have an updated plans of care for months. The ADM/DPCS stated that the plan of care needed to be updated at least every 2 weeks because patients’ condition might have changed, and patients should have a copy of their current POC at home and be placed in their hospice folder.    During a review of the HA’s policy and procedure (P&P) titled, IDG Care Planning Process, revised February 2021, the P&P indicated an individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments. The plan of care includes all services necessary for the palliation and management of the terminal illness and related conditions.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to inform five of fourteen sampled patients (Patient 1, Patient 2, Patient 8, Patient 9, and Patient 11) about the services the HA provided and the limitations of these services. This deficient practice resulted in the violation of the patients' rights to be fully informed about the purpose of the hospice care services and its specific limitations. --- a. During a review of Patient 1’s Personal Information indicated Patient 1 was admitted to the HA on 10/1/2024 with diagnoses that included atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) without angina pectoris (chest pain caused by reduced blood flow to the heart muscle) and type 2 diabetes mellitus (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to elevated blood sugar levels).During a review of Patient 1’s LCD Hospice Eligibility Determination (Local Coverage Determination Hospice Eligibility Determination – used by hospice providers to determine eligibility for beneficiaries of hospice benefits), dated 5/20/2025 indicated Patient 1 did not qualify per LCD guidelines. During a review of Patient 1’s Physician’s Certification for Hospice Benefit for the certification period of 5/29/2025 to 7/27/2025 (also known as CTI or Certification of Terminal Illness, a document stating that a patient's medical prognosis indicates a life expectancy of six months or less if the illness runs its normal course, must be completed by a physician), the physician narrative and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 1.During a joint home visit at Patient 1’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 11:20 a.m., Patient 1 was observed awake, alert, and oriented to person, place, and time (aware of his own identity, current location, and the current date and time). Patient 1 was observed walking independently without assistive device. Patient 1 was Spanish speaking. b. During a review of Patient 2’s Personal Information indicated Patient 2 was admitted to the HA on 10/1/2024 with diagnoses that included acute on chronic combined systolic and diastolic heart failure (a condition where a patient with previously stable, chronic heart failure experiences a sudden worsening of symptoms, due to both systolic [pumping] and diastolic [filling] dysfunction) and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure.The last completed LCD Hospice Eligibility Determination for Patient 2 was dated 4/25/2025. Patient 2 was currently in certification period #4, effective from 5/29/2025 to 7/27/2025.During a review of Patient 2’s Physician’s Certification for Hospice Benefit/CTI for the certification period of 5/29/2025 to 7/27/2025 (certification #4), the RN assessment narrative, physician narrative, and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 1.During a joint home visit at Patient 2’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 12:10 p.m., Patient 2 was observed awake, alert, and oriented to person, place, and time. Patient 2 is the wife of Patient 1. Patient 2 was Spanish speaking.During an interview with Patient 1 and Patient 2 in their native language (Spanish) on 6/25/2025, at 12:48 p.m., Patient 1 and Patient 2 stated they were never informed by their physicians that they had terminal illness and had life expectancy of 6 months or less. Patient 1 stated he was seen by his primary care physician (PCP, health care providers that offer routine checkups, vaccines, and non-emergency medical care) 10 days prior, and the physician did not mention terminal illness or hospice care. Patient 1 stated he had an upcoming appointment with his cardiologist for a test, “to look at my arteries.” Patient 1 stated his cardiologist never told him that he was going to die in 6 months. Patient 1 and Patient 2 were asked what they knew about hospice services, Patient 2 stated, “It’s a program to help you with dentist appointments, doctor appointments, medications, things like that.” Patient 2 stated she saw an advertisement in Spanish on television that offered the services she mentioned above to elderly people. Patient 2 stated she called the phone number in the advertisement and a nurse came to their house not long after that and enrolled them in hospice.During an interview with the Director of Patient Care Services (DPCS) on 6/27/2025, at 12:38 p.m., the DPCS stated that a foundation the HA worked with referred Patient 1 and Patient 2 to the HA “because they needed help.” The DPCS stated she explained about hospice services to both patients but probably the patients did not understand or remember. c. During a review of Patient 8’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 8’s start of care (SOC) date of 2/3/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery (blood vessels that supply blood to the heart muscle) without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 8’s clinical record titled, Plan of Care (POC) Summary, the POC Summary indicated an order dated 2/3/2025, for the skilled nurse (SN) to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the registered nurse (RN) to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.   During a joint home visit at Patient 8’s residence, on 6/25/2025, at 11 a.m., with LVN 2, Patient 8 was observed awake, alert, oriented x 3 (to person, place, and time), ambulatory using a cane, and was independent of her care. Patient 8 was observed to have normal breathing, has no dyspnea (shortness of breath), and Patient 8 stated she did not have chest pain or discomfort. During an interview, on 6/25/2025, at 11:40 a.m., with Patient 8, Patient 8 stated that no one from the HA explained to her regarding what hospice care was, that she did not have terminal illness and was not dying, and that she signed up for hospice care because she was told by HA staff (unidentified) that they could supervise and check on her health condition, be visited by a nurse once a week to monitor her blood pressure, and can provide her with medical supplies and/or equipment.  d. During a review of Patient 9’s Face Sheet, the face sheet indicated Patient 9’s SOC date was on 12/3/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 8’s clinical record titled, POC Summary, the POC Summary indicated an order dated 12/3/2024, for the SN to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.   During a phone interview, on 6/25/2025, at 2:07 p.m., with Patient 9 stated that she was fully independent of her care, was still in the process of looking for a job, was not dying, does not have terminal illness, and that the HA staff did not explain to her what hospice care was.  e. During a review of Patient 11’s Face Sheet, the face sheet indicated Patient 11’s SOC date of 4/3/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 11’s clinical record titled, POC Summary, the POC Summary indicated an order dated 4/3/2025, for the SN to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.   During a phone interview, on 6/25/2025, at 4:06 p.m., with Patient 11 stated she was not referred by her own regular physician for hospice care, did not know the hospice Medical Director, and that she received a phone call one morning from the HA and offered her a nurse to visit once a week to take care and monitor her health status and provided her with protein shakes. Patient 11 stated that she was fully independent of her care, was not dying, was not confined to bed or chair, never had cardiac (relating to the heart) symptoms like chest pain, palpitations or shortness of breath, took the bus regularly for errands, and that the HA staff did not explain to her what hospice care was. During a review of the agency’s policy and procedure (P&P) titled, Election of Hospice Care Policy/Designation of Attending Physician/Election Statement, revised February 2021, the P&P indicated at time of admission, each patient will be informed of the Hospice philosophy of care and required to sign an election statement. The election statement must include the following:-         Identification of the particular Hospice that will provide care to the patient.-         The patient or representative’s acknowledgement that he or she has been given a full understanding of the palliative rather than curative nature of Hospice care, as it relates to the patient’s terminal illness.-         Acknowledgement that certain Medicare services are waived by the election.-         The effective date of the election, which may be the first day of Hospice care or a later date, but may be no earlier than the date of the election statement.-         The signature of the patient or representative.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill [patients who has six months or less to live]patients) failed to ensure the Condition of Participation (CoP-refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) regarding the Initial and Comprehensive Assessment (an assessment to identify the physical, psychosocial [relating social conditions to mental health], 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) of patients was met as follows: --- The hospice agency failed to conduct and document a comprehensive assessment that reflected the current and accurate health status to identify patients' need for hospice care (a specialized care that provides comfort and emotional, social, and spiritual support for people nearing the end of life) and services related to hospice eligibility and management of terminal illness for five of 14 sampled patients (Patient 1, Patient 2, Patient 8, Patient 9, and Patient 11). As a result, the non-compliance has the potential for Patient 1, Patient 2, Patient 8, Patient 9 and Patient 11, to lose their hospice eligibility/hospice benefits and not receive hospice care when needed in the future; and had the potential to not receive the necessary care and services that could lead to emotional and psychological stress, and potential hospitalization and death. (Refer to L524)This systemic practice resulted in the failure of the hospice agency to deliver statutorily (decided and controlled by law) mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the quality of care are provided to patients certified to receive hospice benefits. 2. The hospice agency failed to review all the medications and update the medication profile with currently used medications for two of fourteen sampled patients (Patient 1 and Patient 2). (Refer to L530). This failure had the potential to put the patients at risk for medication errors and adverse drug reactions.3. The hospice agency 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) all working together to create a comprehensive and customized hospice plan of care for each patient) met to discuss and update the patient’s comprehensive assessment at least every 15 days for five of fourteen sampled patients (Patient 8, Patient 9, Patient 11, Patient 13, and Patient 14). (Refer to L533).This failure resulted in the IDG not knowing the patient’s status, their identified needs, interventions, and significant changes in the patients' condition.

Based on observation, interview, and record review, the hospice agency (HA- agency providing care to terminally ill patients who has six months or less to live) failed to conduct and document a comprehensive assessment that reflected the patient's current and accurate health status and identify patients' need for hospice care (a specialized care that provides comfort and emotional, social, and spiritual support for people nearing the end of life) and services related to hospice eligibility and management of terminal illness for 5 of 14 sampled patients (Patient 1, Patient 2, Patient 8, Patient 9, and Patient 11). As a result, the non-compliance has the potential for Patient 1, Patient 2, Patient 8, Patient 9 and Patient 11, to lose their hospice eligibility/hospice benefits and not receive hospice care when needed in the future, and had the potential to not receive the necessary care and services that could lead to emotional and psychological stress, and potential hospitalization and death.  On 6/27/2025, at 1:56 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s Administrator/Director of Patient Care Services (ADM/DPCS), related to the Hospice Agency’s failure to conduct and document a comprehensive assessment that reflected the patient’s current and accurate health status and identify the patient’s need for hospice care and services related to hospice eligibility and management of terminal illness for 5 of 14 sampled patients (Patient 1, Patient 2, Patient 8, Patient 9, and Patient 11). On 6/27/2025, at 3:50 p.m., the Hospice Agency was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 6/27/2024, at 4:00 p.m., the survey team completed the survey tasks and conducted an exit conference in the presence of the ADM/DPCS and Office Manager, with the IJ not removed. --- c. During a review of Patient 8’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 8’s start of care (SOC) date of 2/3/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery (blood vessels that supply blood to the heart muscle) without angina pectoris (a type of chest pain caused by reduced blood flow to the heart).During a review of Patient 8’s clinical record titled, Plan of Care (POC) Summary, the POC Summary indicated an order dated 2/3/2025, for the skilled nurse (SN) to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the registered nurse (RN) to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.   During a joint home visit at Patient 8’s residence, on 6/25/2025 at 11:00 a.m. with LVN 2, Patient 8 was observed awake, alert, oriented x 3 (to person, place, and time), ambulatory using a cane, and was independent of her care. Patient 8 was observed to have normal breathing, has no dyspnea (shortness of breath), and Patient 8 stated she did not have chest pain or discomfort.During an interview, on 6/25/2025, at 11:40 a.m., with Patient 8, Patient 8 stated that no one from the HA explained to her regarding what hospice care was, that she did not have terminal illness and was not dying, and that she signed up for hospice care because she was told by HA staff (unidentified) that they could supervise and check on her health condition, be visited by a nurse once a week to monitor her blood pressure, and can provide her with medical supplies and/or equipment. Patient 8 stated she was not referred by her own primary physician to hospice care, and that she never met, talked to or discussed her health condition/status with the hospice Medical Director. Patient 8 stated that she’s on medication for anxiety (a feeling of worry, nervousness, or fear) for years and would be more anxious and would feel helpless if she would lose hospice benefit in the future.During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 8’s Physician’s Certification for Hospice Benefit also known as Certification of Terminal Illness (CTI, a document required by Medicare and other payers to certify that a patient has a life expectancy of six months or less, assuming the illness runs its normal course) for certification #2 dated from 5/4/2025 to 8/1/2025. The ADM/DPCS stated and confirmed the CTI form was not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 8’s admission to hospice care.During a concurrent interview and record review, on 6/27/2025 at 11:45 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 8’s clinical record titled, History of Nursing Assessment. The ADM/DPCS stated and confirmed there was no Comprehensive Recertification Assessment conducted for Patient 8 for the current certification period from 5/4/2025 to 8/1/2025. The ADM/DPCS stated the purpose of the comprehensive assessment was to evaluate the patients’ need, the overall condition and his or her current health status to continue hospice care and should have been conducted within 5 days of the new certification period. The ADM/DPCS further stated that without the assessment, the agency staff would not know patient needs and what to care for related to the patient's terminal illness.d. During a review of Patient 9’s Face Sheet, the face sheet indicated Patient 9’s SOC date of 12/3/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a review of Patient 8’s clinical record titled, POC Summary, the POC Summary indicated an order dated 12/3/2024, for the SN to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.   During a phone interview, on 6/25/2025, at 2:07 p.m., with Patient 9, Patient 9 stated that she was fully independent of her care, was still in the process of looking for a job, was not dying, does not have terminal illness, and that the HA staff did not explain to her what hospice care was. Patient 9 stated she was not referred by her own regular physician to hospice care, and that she never met, talked to or discussed her health condition/status with the hospice Medical Director. Patient 9 stated that it would be pretty bad if she will lose her hospice benefit in the future.During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 9’s CTI forms for certification #2 dated from 3/3/2025 to 5/31/2025, and for certification #3 from 6/1/2025 to 7/30/2025. The ADM/DPCS stated and confirmed the CTI forms for certification #2 and #3 were not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 9’s admission to hospice care.During a concurrent interview and record review, on 6/27/2025 at 11:45 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 9’s clinical record titled, History of Nursing Assessment. The ADM/DPCS stated and confirmed there was no Comprehensive Recertification Assessment conducted for Patient 9 for the certification period starting from 3/3/2025 to 5/31/2025 and for the current certification period from 6/1/2025 to 7/30/2025. The ADM/DPCS stated the purpose of the comprehensive assessment was to evaluate the patients’ need, the overall condition and his or her current health status to continue hospice care and should have been conducted within 5 days of the new certification period. The ADM/DPCS further stated that without the assessment, the agency staff would not know patient needs and what to care for related to the patient's terminal illness.e. During a review of Patient 11’s Face Sheet, the face sheet indicated Patient 11’s SOC date of 4/3/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a review of Patient 11’s clinical record titled, POC Summary, the POC Summary indicated an order dated 4/3/2025, for the SN to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.   During a phone interview, on 6/25/2025, at 4:06 p.m., with Patient 11, Patient 11 stated she was not referred by her own regular physician to hospice care, that she does not know the hospice Medical Director, and that she just received a phone call one morning from the HA and offered her a nurse visit once a week to take care and monitor her health status and provided her with protein shakes. Patient 11 stated that she was fully independent of her care, was not dying, was not confined to bed or chair, never had cardiac (relating to the heart) symptoms like chest pain, palpitations or shortness of breath, took the bus regularly for errands, and that the HA staff did not explain to her what hospice care was. Patient 11 stated that she would be worried if she really needed hospice care in the future and will not be approved for it.  During a concurrent interview and record review, on 6/27/2025 at 12:05 p.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 11’s Comprehensive Nursing Assessment dated 4/3/2025. The ADM/DPCS stated she conducted the assessment on 4/3/2025 and Patient 11 was assessed to be on NYHA IV level for heart disease (or New York Heart Association Class IV – patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort, and symptoms occurs at rest). The ADM/DPCS was unable to provide an explanation when asked why she assessed Patient 11 to be on NYHA IV level for heart disease when Patient 11 stated during an interview that she never had any cardiac symptoms, was not confined to bed or chair, and still takes the bus regularly for errands.During a review of the agency’s policy and procedure (P&P) titled Initial Assessment/Comprehensive Assessment, revised February 2021, the P&P indicated each patient admitted by Hospice will have an appropriate initial assessment and comprehensive assessment performed and documented which promote the patient's well-being, comfort and dignity throughout the dying process. The comprehensive assessment will identify the patient’s need for hospice care and identify the patient’s need for physical care, psychosocial and emotional care, spiritual care, and all areas of hospice care related to the palliation and management of the terminal illness and related conditions.During a review of the agency’s P&P titled Patient Admission Criteria, revised June 2019, the P&P indicated one of the criteria for admission is Medicare patients must be certified as being terminally ill with a prognosis of six months or less, if the terminal illness runs its normal course. Hospice admits a patient only on the recommendation of the Medical Director in consultation with, or input from the patient’s attending physician (if any).   a.During a review of Patient 1’s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 10/1/2024 diagnosis that included atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) without angina pectoris (chest pain caused by reduced blood flow to the heart muscle) and type 2 diabetes mellitus (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to elevated blood sugar levels).During a review of Patient 1’s electronic health record on 6/24/2025, there was no recertification assessment for the current certification period, effective from 5/29/2025 to 7/27/2025.During a review of Patient 1’s LCD Hospice Eligibility Determination (Local Coverage Determination Hospice Eligibility Determination – used by hospice providers to determine eligibility for beneficiaries of hospice benefits), dated 5/20/2025, the LCD Hospice Eligibility Determination indicated that Patient 1 did not qualify per LCD guidelines. During a review of Patient 1’s Physician’s Certification for Hospice Benefit for the certification period of 5/29/2025 to 7/27/2025 (also known as CTI or Certification of Terminal Illness, a document stating that a patient's medical prognosis indicates a life expectancy of six months or less if the illness runs its normal course, must be completed by a physician), the physician narrative and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 1.During a joint home visit at Patient 1’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 11:20 a.m., Patient 1 was observed awake, alert, and oriented to person, place, and time (aware of his own identity, current location, and the current date and time). Patient 1 was also observed walking independently without assistive device. Patient 1 was Spanish speaking.b.During a review of Patient 2’s Personal Information, the Personal Information indicated that Patient 2 was admitted to the HA on 10/1/2024 diagnosis that included acute on chronic combined systolic and diastolic heart failure (a condition where a patient with previously stable, chronic heart failure experiences a sudden worsening of symptoms, due to both systolic [pumping] and diastolic [filling] dysfunction) and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure. During a review of Patient 2’s electronic health record on 6/24/2025, there was no recertification assessment for the current certification period, effective from 5/29/2025 to 7/27/2025.The last completed LCD Hospice Eligibility Determination for Patient 2 was dated 4/25/2025. Patient 2 was currently in certification period #4, effective from 5/29/2025 to 7/27/2025.During a review of Patient 2’s Physician’s Certification for Hospice Benefit/CTI for the certification period of 5/29/2025 to 7/27/2025, the RN assessment narrative, physician narrative, and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 1.During a joint home visit at Patient 2’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 12:10 p.m., Patient 2 was observed awake, alert, and oriented to person, place, and time. Patient 2 is the wife of Patient 1. Patient 2 was Spanish speaking.During an interview with Patient 1 and Patient 2 in their native language (Spanish) on 6/25/2025, at 12:48 p.m., Patient 1 stated he had never been informed by any of his physicians that he had a terminal illness and had a life expectation of 6 months or less. Patient 1 stated he was seen by his primary care physician (PCP, health care providers that offer routine checkups, vaccines, and non-emergency medical care) 10 days prior, and the physician did not mention terminal illness or hospice care. Patient 1 stated he had an upcoming appointment with his cardiologist a test, “to look at my arteries.” Patient 1 stated his cardiologist never told him that he was going to die in 6 months. During the same interview, Patient 2 denied having heart problems. Patient 2 stated she had respiratory issues, which were relieved with breathing treatments. Patient 2 stated she did not have a terminal illness. Patient 2 stated both she and Patient 1 routinely saw their doctors, and she believed if they were dying the doctors would have let them know. During a telephone interview with Patient 2 on 6/27/2025 at 9:03 a.m., Patient 2 stated that her husband (Patient 1) was the one doing the grocery shopping, housekeeping, and cooking. Patient 2 stated she helped her husband as well with the household chores. During a concurrent interview and record review with the Director of Patient Care Services (DPCS) on 6/27/2025 at 11:09 a.m., the DPCS reviewed Patient 1’s and Patient 2’s recertification assessment for the current certification period, effective 5/29/2025 to 7/27/2025. The DPCS also reviewed both patients’ LCD Hospice Eligibility Determination and CTIs. The DPCS stated Patient 1 was not qualified per LCD guidelines because the LCD assessment was not completed. The DPCS also stated she had just documented Patient 1’s recert assessment on 6/26/2025. The DPCS stated Patient 1 was recertified to receive hospice services without appropriate assessment.During the same interview, the DPCS stated that Nurse Practitioner 1 (NP1) had just documented Patient 2’s recert assessment on 6/24/2025. The DPCS stated, “NP 1 is very busy.” The DPCS stated Patient 2 was recertified to receive hospice services without appropriate assessment.The DPCS stated that recertifying patients to hospice without appropriately assessing them could have negative outcomes, such as patients were no longer suitable for hospice, or patients might have different needs from the hospice due to their changing conditions.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) staff failed to review all the medications and update the medication profiles with currently used medications for two of fourteen sampled patients (Patient 1 and Patient 2). This deficient practice had the potential to put the patients at risk for medication errors and adverse drug reactions. --- a. During a review of Patient 1’s Personal Information indicated Patient 1 was admitted to the HA on 10/1/2024 with diagnoses that included atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) without angina pectoris (chest pain caused by reduced blood flow to the heart muscle) and type 2 diabetes mellitus (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to elevated blood sugar levels).During a review of Patient 1’s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes) List indicated that one of the diabetes medications Patient 1 was taking included Humulin N Kwik Pen (a prefilled disposable insulin pen containing Humulin N [insulin isophane human], an intermediate-acting human insulin used to control blood sugar levels in adults and children with diabetes mellitus) Pre-filled pen 100 units/ml (milliliter, a measurement unit) suspension for injection, 12 units subcutaneous (under the skin) once a day in the morning.During a joint home visit at Patient 1’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 11:20 a.m., Patient 1 was observed awake, alert, and oriented to person, place, and time (aware of his own identity, current location, and the current date and time). Patient 1 was also observed walking independently without assistive device. Patient 1 was Spanish speaking. During the home visit, a medication review was performed with LVN 1. Humulin N Kwik Pen Pre-filled pen 100 units/ml was not observed at Patient 1’s residence. Instead, Insulin Glargine 100 units/ml was observed, with the instruction on the label indicated that Patient 1 would need to inject 12 units subcutaneously in the morning to control blood sugar. Patient 1 also had Atorvastatin (a medication to treat high cholesterol) 20 mg (milligram, a measurement unit) tablet, with the label instructing to take one tablet by mouth daily. The filled date on the label was on 4/24/2025.During an interview with Patient 1 on 6/25/2025 at 11:50 a.m., Patient 1 stated he was no longer on Humulin N, but he was on Insulin Glargine. Patient 1 stated he would inject 12 units subcutaneously in the morning, daily. Patient 1 stated he did not remember when his physician switched Humulin N to Insulin Glargine. Patient 1 stated he had been taking Atorvastatin for a few months.During an interview with LVN 1 on 6/25/2025 at 12 p.m., LVN 1 stated she was not aware that Patient 1 was on a different kind of insulin. LVN 1 stated she saw Patient 1 the day before (6/24/2025) and asked him if he had all his medications, including his insulin, and Patient 1 said he did. LVN 1 stated she did not physically go over Patient 1’s medications. b. During a review of Patient 2’s Personal Information indicated Patient 2 was admitted to the HA on 10/1/2024 diagnosis that included acute on chronic combined systolic and diastolic heart failure (a condition where a patient with previously stable, chronic heart failure experiences a sudden worsening of symptoms, due to both systolic [pumping] and diastolic [filling] dysfunction) and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure. During a joint home visit at Patient 2’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 12:10 p.m., Patient 2 was observed awake, alert, and oriented to person, place, and time. Patient 2 is the wife of Patient 1. Patient 2 was Spanish speaking.During the home visit, a medication review was performed with LVN 1. The following medications were found at Patient 2’s residence but not listed in her Current Treatment/Medication/DME List:-         Fasenra (an injection to treat severe asthma) pen injection 30 mg/ml (milligram per milliliter, a unit measurement), inject 1 ml subcutaneously (under the skin) every 8 weeks.-         Ipratropium Bromide (a breathing treatment) 21 mcg (microgram; a unit measurement) inhaler, 2 puffs in AM and 2 puffs in PM.-         Oyster shell calcium-Vitamin D3 (a dietary supplement to treat vitamin D deficiency) 500 mg-5 mg (200 unit) tablet, take one tablet by mouth twice daily.-          MagOx 400 (a dietary supplement to maintain adequate magnesium level in the body) tablet, one tablet by mouth daily.-         Cholecalciferol (a dietary supplement to treat vitamin D deficiency) 25 mcg (1000 units) tablet, take one tablet by mouth daily. -         Ferrous Sulfate (a dietary supplement to treat iron deficiency) 325 mg (iron 65 mg) tablet, one tablet daily per patient.-         Multivitamin with minerals (a dietary supplement) tablet, one tablet daily per patient.-         Vitamin B12 (a dietary supplement 1000 mcg tablet, one tablet every other day per patient.        Hydrochlorothiazide (a medication to treat fluid retention and/or high blood pressure)  12.5 mg tablet was not available at Patient 2’s residence. During an interview with LVN 1 on 6/25/2025 at 12:37 p.m., LVN 1 stated she was not aware of Patient 2’s medication discrepancy. Per LVN 1, if she was aware she would have reported it to the hospice’s office. LVN 1 asked the surveyor how she was supposed to know the patient had new medications if the patient did not report it to her. During an interview with Patient 2 on 6/25/2025 at 12:42 p.m., Patient 2 stated that she had been taking the medications listed above for a few months, and she has not had any medication change lately. Patient 2 stated she did not remember when her doctor discontinued Hydrochlorothiazide.During a concurrent interview and record review with the Director of Patient Care Services on 6/26/2025, at 11:18 a.m., the DPCS reviewed Patient 1’s and Patient 2’s Current Treatment/Medication/DME List. The DPCS stated the visiting nurse was responsible for conducting medication review with every visit, comparing the actual medications at the patient’s house with the medications in the Current Treatment/Medication/DME List. The DPCS stated that inaccurate medication list could lead to medication error and unmonitored side effects. During a review of the HA’s policy and procedure (P & P), titled “Medication Profile,” revised June 2019, the P & P indicated that all prescribed medications, over-the-counter medications, and home remedies will be documented on the medication profile, as well as the date medication prescribed, and dose, frequency, and route. The medication profile will be reviewed every home visit, updated as changes occur and reviewed by the IDG.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG/IDT - various hospice professionals [Registered Nurse [Rn], Medical Doctor [MD], Medical Social Worker {MSW], and Spiritual Counselor[SC]) all working together to create a comprehensive and customized hospice plan of care for each patient) met to discuss and update the patient’s comprehensive assessment at least every 15 days for five of fourteen sampled patients (Patient 8, Patient 9, Patient 11, Patient 13, and Patient 14).   This failure resulted in the IDG not knowing the patient’s health status, their identified needs, interventions, and significant changes in the patients' condition. --- a.  During a review of Patient 8’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 8’s start of care (SOC) date of 2/3/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a review of Patient 8's Plan of Care (POC) Summary form indicated there was an order dated 2/3/2025 for the IDT to review patient’s status every 14 days and as needed to evaluate changes in condition.During a record review of Patient 8’s medical record form titled, History of POC/IDG, the History of POC/IDG indicated the last meeting conducted by the IDG was on 3/12/2025, and there was no more update to the patient’s comprehensive assessment at least every 15 days after 3/12/2025.   b. During a review of Patient 9’s Face Sheet, the face sheet indicated Patient 9’s SOC date of 12/3/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.  During a review of Patient 9's POC Summary form indicated there was an order dated 12/3/2024 for the IDT to review patient’s status every 14 days and as needed to evaluate changes in condition.During a record review of Patient 9’s medical record form titled, History of POC/IDG indicated the last meeting conducted by the IDG was on 1/2/2025, and there was no more update to the patient’s comprehensive assessment at least every 15 days after 1/2/2025. c. During a review of Patient 11’s Face Sheet, the face sheet indicated Patient 11’s SOC date of 4/3/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a review of Patient 11's POC Summary form indicated there was an order dated 4/3/2025 for the IDT to review patient’s status every 14 days and as needed to evaluate changes in condition.During a record review of Patient 11’s medical record form titled, History of POC/IDG indicated the last meeting conducted by the IDG was on 4/9/2025, and there was no more update to the patient’s comprehensive assessment at least every 15 days after 4/9/2025. d. During a review of Patient 13’s Face Sheet, the face sheet indicated Patient 13’s SOC date of 4/17/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with refractory angina pectoris (a chronic and persistent form of angina, a type of chest pain caused by reduced blood flow to the heart). The face sheet further indicated Patient 13 was discharged from hospice service on 3/12/2025 due to extended prognosis.During a review of Patient 13's POC Summary form, the POC Summary indicated there was an order dated 4/20/2024 for the IDT to review patient’s status every 14 days and as needed to evaluate changes in condition.During a record review of Patient 13’s medical record form titled, History of POC/IDG, the History of POC/IDG indicated the last meeting conducted by the IDG was on 11/6/2024, and there was no more update to the patient’s comprehensive assessment at least every 15 days after 11/6/2024. e. During a review of Patient 14’s Face Sheet, the face sheet indicated Patient 14’s SOC date of 11/21/2024, with a terminal diagnosis of acute on chronic combined systolic and diastolic heart failure. The face sheet further indicated Patient 14 was discharged from hospice service on 5/24/2025.During a review of Patient 14's POC Summary form, the POC Summary indicated there was an order dated 11/25/2024 for the IDT to review patient’s status every 14 days and as needed to evaluate changes in condition.During a record review of Patient 14’s medical record form titled, History of POC/IDG indicated the last meeting conducted by the IDG was on 12/4/2024, and there was no more update to the patient’s comprehensive assessment at least every 15 days after 12/4/2024.During an interview with the Administrator/Director of Patient Care Services (ADM/DPCS), on 6/26/2025, at 10:52 a.m., stated she was aware Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 11, Patient 13, and Patient 14 did not have the updated comprehensive assessments and plans of care for months. The ADM/DPCS stated the patient’s comprehensive assessment and plan of care needed to be updated at least every 2 weeks because patients’ condition might have changed, and the IDG members needed to address it. During a review of the HA’s policy and procedure (P&P) titled, Reassessments/Update to the Comprehensive Assessment, revised February 2021, the P&P indicated the update of the comprehensive assessment must be accomplished by the Hospice IDG (in collaboration with the patient's attending physician, if any) and must consider changes that have taken place since the initial assessment. It must include information on the patient's progress toward desired outcomes, as well as a reassessment of the patient's response to care. The assessment updates must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (CoP-conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal health insurance program that helps people pay for health care] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), Care Planning, and Coordination of Services for eight of 14 sampled patients (Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 11, Patient 13, and Patient 14) were met as follows: --- d. For Patient 8, who had a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of atherosclerotic heart disease of native coronary artery without angina pectoris, there was no current care plan developed for pain management, fall/safety precautions, and symptom management.e. For Patient 9, who had a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, there was no current care plan developed for respiratory (anything related to respiration or how we breathe) care and management, and bleeding precautions.f. For Patient 11, who had a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, there was no current care plan developed for pain management, cardiovascular (relating to the heart and blood vessels) care, and symptom management.g. For Patient 13, who had a terminal diagnosis of atherosclerotic heart disease of native coronary artery with refractory angina pectoris (a chronic and persistent form of angina, a type of chest pain caused by reduced blood flow to the heart), there was no care plan developed for pain management, cardiovascular care, and symptom management.h. For Patient 14, who had a terminal diagnosis of acute on chronic combined systolic and diastolic heart failure, there was no care plan for pain management, cardiovascular care, and symptom management.  1. The HA failed to develop an individualized plan of care (POC, a document  detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) for eight of fourteen sampled patients (Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 11, Patient 13, and Patient 14) based on identified initial and updated assessments to address the management of health status of the patients. (Refer to L545).a. For Patient 1, who had diagnosis that included atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) without angina pectoris (chest pain caused by reduced blood flow to the heart muscle) and type 2 diabetes mellitus (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to elevated blood sugar levels), the HA did not have interventions to manage Patient 1’s diabetes and monitor his blood sugar levels.b. For Patient 2, who had diagnosis that included acute on chronic combined systolic and diastolic heart failure (a condition where a patient with previously stable, chronic heart failure experiences a sudden worsening of symptoms, due to both systolic [pumping] and diastolic [filling] dysfunction) and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure, the HA did not have interventions to manage Patient 2’s hypertension and monitor her blood pressure levels.c. For Patient 7, who had diagnosis that included acute combined systolic and diastolic heart failure and hypertensive heart disease with heart failure, the HA did not have interventions to manage Patient 2’s hypertension and monitor her blood pressure levels.d. For Patient 8e. For Patient 9f. For Patient 11g. For Patient 13h. For Patient 14 As a result, Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 11, Patient 13, and Patient 14 received hospice services without a written plan of care that included management of terminal illness, which had the potential to experience undetected serious complications that could lead to serious harm, hospitalization, and/or death.The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with the federal regulations for IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure that an individualized plan of care (POC, a document  detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved) based on identified initial and updated assessments to address the management of health status  was developed for eight of 14 sampled patients (Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 11, Patient 13, and Patient 14) by:a.      Failing to ensure that Patient 1, who had a diagnosis of type 2 diabetes mellitus (a chronic condition that happens when a patient has persistently high blood sugar levels), had a care plan with interventions to manage Patient 1’s diabetes and monitor his (Patient 1) blood sugar levels.b.     Failing to ensure that Patient 2, who had a diagnosis that included systolic and diastolic heart failure (Systolic [The blood pressure when the heart is contracting [tightening] heart failure occurs when the heart muscle is weakened and can't contract forcefully enough to pump adequate blood out to the body. Diastolic [the force of blood against artery walls when the heart is relaxed between beats] heart failure occurs when the heart muscle becomes stiff, making it difficult for the heart to relax and fill with blood properly between beats, and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure, had a care plan with interventions to manage Patient 2’s hypertension and monitor her (Patient 2’s) blood pressure levels.c.      Failing to ensure that Patient 7, who had a diagnosis that included acute combined systolic and diastolic heart failure and hypertensive heart disease with heart failure, had a care plan with interventions to manage Patient 7’s hypertension and monitor her (Patient 7’s) blood pressure levels.d.     Failing to ensure that Patient 8, who had a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaques [fat build up] that has built up in the arteries supplying blood to the heart, but this blockage isn't causing noticeable chest pain), and required medication to treat head and neck pain,  had a care plan developed for pain management, fall/safety precautions, and symptom management.e.      Failing to ensure that Patient 9, who had a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, had a current care plan developed for respiratory (anything related to respiration or how we breathe) care and management (Atherosclerotic heart disease of the native coronary artery, even without angina pectoris can lead to respiratory issues, particularly shortness of breath [dyspnea]), and bleeding precautions.f.        Failing to ensure that Patient 11, who had a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, had a current care plan developed for pain management, cardiovascular (relating to the heart and blood vessels) care, and symptom management.g.      Failing to ensure that Patient 13, who had a terminal diagnosis of atherosclerotic heart disease of native coronary artery with refractory angina pectoris (a chronic and persistent form of angina, a type of chest pain caused by reduced blood flow to the heart), there was no care plan developed for pain management, cardiovascular care, and symptom management.h.      Failing to ensure that Patient 14, who had a diagnosis of acute on chronic combined systolic and diastolic heart failure, had a care plan for pain management, cardiovascular care, and symptom management.These deficient practices resulted in Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 11, Patient 13, and Patient 14 receiving hospice services without a written plan of care that included management of terminal illness, which had the potential to experience undetected serious complications that could lead to serious harm, hospitalization, and/or death. --- d. During a review of Patient 8’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 8’s start of care (SOC) date of 2/3/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a joint home visit at Patient 8’s residence, on 6/25/2025 at 11:00 a.m. with LVN 2, Patient 8 was observed awake, alert, oriented x 3 (to person, place, and time), ambulatory using a cane, and was independent of her care. Patient 8 was observed to have normal breathing, has no dyspnea (shortness of breath), and Patient 8 stated she did not have chest pain or discomfort.During an interview, on 6/25/2025, at 11:40 a.m., with Patient 8, Patient 8 stated that she was taking medications for headache and neck pain, anxiety and depression for several years. Patient 8 further stated that she also had a history of losing her balance and has fallen many times for the past year.During a review of Patient 8’s electronic health record (EHR) on 6/25/2025, the EHR indicated there was no individualized plan of care developed at all for Patient 8 for the current certification period effective date from 5/4/2025 to 8/1/2025.e. During a review of Patient 9’s Face Sheet, the face sheet indicated Patient 9’s SOC date of 12/3/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a phone interview, on 6/25/2025, at 2:07 p.m., with Patient 9, Patient 9 stated that she has shortness of breath at times and used an inhaler (a handheld device that delivers medication directly to the lungs) to relieve her symptoms. Patient 9 stated she also has partially clogged arteries and was taking blood thinner medication (medications that help prevent blood clots from forming or becoming larger).  During a review of Patient 9’s EHR on 6/25/2025, the EHR indicated there was no individualized plan of care developed at all for Patient 9 for the current certification period effective date from 6/1/2025 to 7/30/2025.f. During a review of Patient 11’s Face Sheet, the face sheet indicated Patient 11’s SOC date of 4/3/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a phone interview, on 6/25/2025, at 4:06 p.m., with Patient 11, Patient 11 stated her physician prescribed her medication for blood pressure control and some kind of heart medicine.During a review of Patient 11’s Current Treatment/Medication/DME List, the Current Treatment/Medication/DME List indicated that Patient 11 was taking the following medications:- Aspirin (a medication that prevents blood clots from forming in the arteries) 81 mg, 1 tablet by mouth once a day.- Lisinopril/Hydrochlorothiazide (a medication that treats high blood pressure) 10-25 mg, 1 tablet by mouth once a day.- Atorvastatin Calcium (a medication that reduce the risk of heart and blood vessel problems caused by high cholesterol [fat-like substance found in all cells of the body]) 40 mg, 1 tablet by mouth once a day.During a review of Patient 11’s EHR on 6/25/2025, the EHR indicated there was no current plan of care developed for cardiovascular care, pain management, and symptom management related to terminal illness diagnosis for Patient 11.g. During a review of Patient 13’s Face Sheet, the face sheet indicated Patient 13’s SOC date of 4/17/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with refractory angina pectoris. The face sheet further indicated Patient 13 was discharged from hospice service on 3/12/2025 due to extended prognosis.During a review of Patient 13’s Current Treatment/Medication/DME List, the Current Treatment/Medication/DME List indicated that Patient 13 was taking the following high blood pressure medications:- Amlodipine Besylate 5 mg, 1 tablet by mouth once a day.- Ramipril 10 mg, 1 tablet by mouth once a day.During a review of Patient 13’s EHR on 6/25/2025, the EHR indicated there was no individualized plan of care developed at all for Patient 13 for the most recent certification period effective date from 1/12/2025 to 3/12/2025.h. During a review of Patient 14’s Face Sheet, the face sheet indicated Patient 14’s SOC date of 11/21/2024, with a terminal diagnosis of acute on chronic combined systolic and diastolic heart failure. The face sheet further indicated Patient 14 was discharged from hospice service on 5/24/2025.During a review of Patient 14’s Current Treatment/Medication/DME List, the Current Treatment/Medication/DME List indicated that Patient 14 was taking the following medications:- Amlodipine Besylate (used to treat high blood pressure) 5 mg, 1 tablet by mouth once a day.- Bisoprolol Fumarate (a medication that treats high blood pressure) 5 mg, 1 tablet by mouth once a day.- Atorvastatin Calcium 80 mg, 1 tablet by mouth once a day.- Lisinopril (a medication that treats high blood pressure) 20 mg, 1 tablet by mouth once a day.- Pradaxa (a type of blood thinner medication that treats and prevents blood clots) 110 mg, 1 capsule by mouth twice a day.During a review of Patient 14’s EHR on 6/25/2025, the EHR indicated there was no individualized plan of care developed at all for Patient 14 for the last two most recent certification period effective date from 2/19/2025 to 5/19/2025, and effective date from 5/20/2025 to 7/18/2025.During an interview with the ADM/DPCS on 6/26/2025 at 10:52 a.m., the ADM/DPCS stated that she was aware that Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 11, Patient 13, and Patient 14 did not have an updated plan of care for months. The ADM/DPCS stated the plan of care needed to be updated at least every 2 weeks because patients’ condition might have changed, and the IDG members needed to address it. The ADM/DPCS stated, “It’s horrible that these patients don’t have a plan of care. It’s a horrible mistake.” Regarding Patient 1, the ADM/DPCS stated that since the patient was diabetic, on insulin and two types of oral diabetes medication, he needed to be monitored. The ADM/DPCS stated the interventions related to endocrine (a system of glands and organs that produce and release hormones, which are chemical messengers that travel through the bloodstream to regulate various bodily functions) for Patient 1 was missed due to the lack of care plan.During a review of the HA’s policy and procedure (P&P) titled IDG Care Planning Process, revised February 2021, the P&P indicated that the care of plan specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. The P&P further indicated that all care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any), the patient, or representative and the primary caregiver in accordance with the patient’s needs. An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments.     a. During a review of Patient 1’s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 10/1/2024 diagnosis that included atherosclerotic heart disease of native coronary artery without angina pectoris and type 2 diabetes mellitus.During a review of Patient 1’s electronic health record on 6/24/2025, there was no individualized plan of care developed for Patient 1 for the current certification period, effective from 5/29/2025 to 7/27/2025.During a review of Patient 1’s Current Treatment/Medication/DME (Durable Medical Equipment, medical equipment that is used repeatedly and is primarily used for medical purposes) List, the Current Treatment/Medication/DME List indicated that Patient 1 was taking medications for diabetes:-         Glipizide (a medication used to treat type 2 diabetes) 10 mg (milligram, a measurement unit) tablet, one tablet twice a day.-         Humulin N KwikPen (a prefilled disposable insulin pen containing Humulin N [insulin isophane human], an intermediate-acting human insulin used to control blood sugar levels in adults and children with diabetes mellitus) Pre-filled pen 100 units/ml (milliliter, a measurement unit) suspension for injection, 12 units subcutaneous (under the skin) once a day in the morning.-         Metformin Hydrochloride (a medication used to treat type 2 diabetes) 500 mg tablet, one tablet once a day. During a joint home visit to Patient 1’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 11:20 a.m., Patient 1 was observed awake, alert, and oriented to person, place, and time (aware of his own identity, current location, and the current date and time). Patient 1 was also observed walking independently without assistive device. Patient 1 was Spanish speaking. During the home visit, a medication review was performed with LVN 1. During the medication review, Humulin N KwikPen Pre-filled pen 100 units/ml was not observed at Patient 1’s residence. Instead, Insulin Glargine 100 units/ml was observed, with the instruction on the label indicated that Patient 1 would need to inject 12 units subcutaneously in the morning to control blood sugar. During an interview with Patient 1 on 6/25/2025 at 11:50 a.m., Patient 1 stated he was no longer on Humulin N, but he was on Insulin Glargine. Patient 1 stated he would inject 12 units subcutaneously in the morning, daily. Patient 1 stated he did not remember when his physician switched Humulin N to Insulin Glargine. When Patient 1 was asked in his native language if he monitored his blood glucose, Patient 1 pointed out to the Freestyle Libre continuous glucose monitor on his left upper arm. Patient 1 then demonstrated how he checked his blood glucose level. Patient 1’s blood glucose level was observed at 128 mg/dl (milligram per deciliter, a measurement unit). Patient 1 stated he usually checked it in the morning before administering Insulin Glargine. Patient 1 stated he did not record his blood sugar readings.b.During a review of Patient 2’s Personal Information, the Personal Information indicated that Patient 2 was admitted to the HA on 10/1/2024 diagnosis that included acute combined systolic and diastolic heart failure and hypertensive heart disease with heart failure. During a review of Patient 2’s electronic health record on 6/24/2025, there was no individualized plan of care developed for Patient 2 for the current certification period, effective from 5/29/2025 to 7/27/2025.During a review of Patient 2’s Current Treatment/Medication/DME List, the Current Treatment/Medication/DME List indicated that Patient 2 was taking the following high blood pressure medications:- Hydralazine Hydrochloride 50 mg tablet, 1 tablet once a day.- Lisinopril 10 mg tablet, 1 tablet once a day.- Metoprolol Tartrate 100 mg tablet, 1 tablet once a day.During a joint home visit to Patient 2’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 12:10 p.m., Patient 2 was observed awake, alert, and oriented to person, place, and time. Patient 2 is the wife of Patient 1. Patient 2 was Spanish speaking.During the home visit, the three blood pressure medications listed in the Current Treatment/Medication/DME List were observed at Patient 2’s residence. During an interview with Patient 2 on 6/25/2025 at 12:45 p.m. in her native language, Patient 2 stated she took the three blood pressure medications as instructed on the medication labels. Patient 2 stated that she and her husband (Patient 1) had been visited by different nurses from the HA. During the joint home visit for Patient 1 and Patient 2, LVN 1 did not assess them. During a telephone interview with LVN 1 on 6/25/2025 at 2:23 p.m., LVN 1 stated she had seen Patient 1 and Patient 2 twice prior to the joint home visit on 6/25/2025. LVN 1 was not aware that Patient 1 and Patient 2 did not currently have a plan of care. LVN 1 stated she checked their vital signs, asked if they had pain, asked if they had concerns during her visits.c.During a review of Patient 7’s Personal Information, the Personal Information indicated that Patient 7 was admitted to the HA on 6/24/2024 diagnosis that included acute combined systolic and diastolic heart failure and hypertensive heart disease with heart failure. Patent 7 was discharged from the HA on 12/10/2024. During a review of Patient 7’s electronic health record on 6/24/2025, there was no individualized plan of care developed for Patient 7 for the most recent certification period prior to discharge, effective from 9/22/2024 to 12/20/2024.During a review of Patient 7’s Current Treatment/Medication/DME List, the Current Treatment/Medication/DME List indicated that Patient 2 was taking the following high blood pressure medications:- Furosemide (a medication  used to treat fluid retention and high blood pressure) 40 mg tablet, 1 tablet twice a day.- Diltiazem Hydrochloride (a medication to treat high blood pressure) 120 mg tablet, 1 tablet once a day.- Hydralazine Hydrochloride (a medication to treat high blood pressure) 10 mg tablet, 1 tablet at bedtime. During an interview with the DPCS on 6/26/2025 at 10:52 a.m., the DPCS stated that she was aware that Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 11, Patient 13, and Patient 14 did not have an updated plan of care for months. The DPCS stated the plan of care needed to be updated at least every 2 weeks because patients’ condition might have changed, and the IDG members needed to address it. The DPCS stated, “It’s horrible that these patients don’t have a plan of care.”Regarding Patient 1, the DPCS stated that since the patient was diabetic, on insulin and two types of oral diabetes medication, he needed to be monitored. The DPCS stated Patient 1 might experience hypoglycemia as a side effect from his diabetes medications. The DPCS stated, “Hypoglycemia is very serious and can be dangerous if not monitored.” The DPCS stated the interventions related to endocrine for Patient 1 were missed due to the lack of care plan.During a review of the HA’s policy and procedure (P & P), titled “IDG Care Planning Process,” revised February 2021, the P & P  indicated that the care of plan specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. The P & P also indicated that all care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any), the patient, or representative and the primary caregiver in accordance with the patient’s needs.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the interdisciplinary group Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) met, reviewed, revised, and documented the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days for three of fourteen sampled patients (Patient 1, Patient 2, and Patient 7).   This failure resulted in Patient 1, Patient 2, and Patient 7 receiving services without an individualized plans of care that were based on their current health and hospice needs. --- a. During a review of Patient 1’s Personal Information indicated Patient 1 was admitted to the HA on 10/1/2024 with diagnoses that included atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) without angina pectoris (chest pain caused by reduced blood flow to the heart muscle) and type 2 diabetes mellitus (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to elevated blood sugar levels).During a review of Patient 1’s Current Treatment/Medication/DME (Durable Medical Equipment, (medical equipment that is used repeatedly and is primarily used for medical purposes) List, indicated on 10/2/2024, the physician ordered the IDG to review patient’s status every 14 days and as needed to evaluate changes in condition. During a review of Patient 1’s History of POC/IDG indicated the last meeting conducted by the IDG was on 11/6/2024, and there was no update and documentation of Patient 1’s plan of care after 11/6/2024. b. During a review of Patient 2’s Personal Information, the Personal Information indicated that Patient 2 was admitted to the HA on 10/1/2024 with diagnoses that included acute on chronic combined systolic and diastolic heart failure (a condition where a patient with previously stable, chronic heart failure experiences a sudden worsening of symptoms, due to both systolic [pumping] and diastolic [filling] dysfunction) and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure.During a review of Patient 2’s Current Treatment/Medication/DME List, indicated that on 10/2/2024, the physician ordered the IDG to review patient’s status every 14 days and as needed to evaluate changes in condition. During a review of Patient 2’s History of POC/IDG indicated the last meeting conducted by the IDG was on 11/6/2024, and there was no update and documentation of Patient 2’s plan of care after 11/6/2024. c. During a review of Patient 7’s Personal Information, the Personal Information indicated that Patient 7 was admitted to the HA on 6/24/2024 with diagnosis that included acute combined systolic and diastolic heart failure and hypertensive heart disease with heart failure. Patent 7 was discharged from the HA on 12/10/2024. During a review of Patient 7’s Current Treatment/Medication/DME List indicated that on 6/24/2024, the physician ordered the IDG to review patient’s status every 14 days and as needed to evaluate changes in condition. During a review of Patient 7’s History of POC/IDG indicated the last meeting conducted by the IDG was on 7/31/2024, and there was no update and documentation of Patient 2’s plan of care after 7/31/2024.During an interview with the DPCS on 6/26/2025 at 10:52 a.m., the DPCS stated that she was aware that Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 11, Patient 13, and Patient 14 did not have the updated plans of care for months. The DPCS stated the plan of care needed to be updated at least every 2 weeks because patients’ condition might have changed, and the IDG members needed to address it. During a review of the HA’s policy and procedure (P & P), titled “IDG Care Planning Process,” revised February 2021, the P & P indicated the IDG (in collaboration with the patient’s attending physician, if any) reviews, revises, and documents the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days.

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live)  failed to ensure home visits were conducted in accordance with the plan of care (POC, a personalized, comprehensive document that outlines the medical, emotional, psychosocial, and spiritual needs of a patient and their family during hospice care) for 1 of 14 sampled patients (Patient 10). This deficient practice had the potential to negatively affect the patients' physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. --- During a review of Patient 10’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 10’s start of care (SOC) date of 2/11/2025, with a terminal diagnosis of hypertensive heart disease (refers to heart conditions that develop as a result of long-term high blood pressure) without heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).  During a review of Patient 10’s clinical record titled, POC Summary indicated an order dated 2/11/2025, for the skilled nurse (SN) to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.   During a review of Patient 10’s medical record titled, History of Visit Notes, the History of Visit Notes indicated there was no SN visit conducted for the month of March 2025, and Patient 10 was only visited once each month by the skilled nurse for the month of April 2025, May 2025, and June 2025. During a concurrent interview and record review, on 6/27/2025 at 1:30 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 10’s History of Visit Notes for 2025. The ADM/DPCS stated and acknowledged Patient 10 was not visited by SN once a week in accordance with the plan of care, and that it was a big mistake. The ADM/DPCS stated if patients are not visited as scheduled, patients’ health will go unnoticed and untreated, potentially leading to further decline. During a review of the HA’s policy and procedure (P&P) titled IDG Care Planning Process, revised February 2021, the P&P indicated that the care of plan specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. The P&P further indicated that all care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any), the patient, or representative and the primary caregiver in accordance with the patient’s needs. The care provided to the patient must be in accordance with the plan of care.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Medical Director was met as follows. --- The HA's Medical Director failed to document a Certification of Terminal Illness (CTI, a document required by Medicare and other payers to certify that a patient has a life expectancy of six months or less, assuming the illness runs its normal course) and review patients’ clinical information that reflected the patients’ current health status and identify patients’ need for continuous hospice care (a specialized care that provides comfort and emotional, social, and spiritual support for people nearing the end of life) and service related to hospice eligibility and management of terminal illness for 11 of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14).  As a result of the non-compliance, Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14 were not eligible to be placed in hospice care that increases the risk of losing their medical services and had the potential to not receive the necessary medical treatment and hospitalization. (Refer to L668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily (decided and controlled by law) mandated compliance with Federal regulation for Medical Director services to ensure the highest quality of patient care were provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the hospice agency (HA- agency providing care to terminally ill patients who has six months or less to live) Medical Director failed to document a Certification of Terminal Illness (CTI, a document required by Medicare and other payers to certify that a patient has a life expectancy of six months or less, assuming the illness runs its normal course) and review patient’s clinical information that reflected the patient's current health status and identify patients’ need for continuous hospice care (a specialized care that provides comfort and emotional, social, and spiritual support for people nearing the end of life) and service related to hospice eligibility and management of terminal illness for 11 of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14).  As a result of the non-compliance, Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14 were not eligible to be placed in hospice care that increases the risk of losing their medical services and had the potential to not receive the necessary medical treatment/services and hospitalization. On 6/26/2025, at 4:19 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the agency’s Administrator/Director of Patient Care Services (ADM/DPCS), related to the Hospice Agency Medical Director’s failure to document a Certification of Terminal Illness and review patient’s clinical information that reflected the patient's current health status and identify patients’ need for continuous hospice care and service related to hospice eligibility and management of terminal illness for 11 of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14).   On 6/27/2025, at 3:50 p.m., the Hospice Agency was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely). On 6/27/2024, at 4 p.m., the survey team completed the survey tasks and conducted an exit conference in the presence of the ADM/DPCS and Office Manager, with the IJ not removed. --- a.During a review of Patient 1’s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 10/1/2024 diagnosis that included atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) without angina pectoris (chest pain caused by reduced blood flow to the heart muscle) and type 2 diabetes mellitus (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to elevated blood sugar levels).During a review of Patient 1’s LCD Hospice Eligibility Determination (Local Coverage Determination Hospice Eligibility Determination – used by hospice providers to determine eligibility for beneficiaries of hospice benefits), dated 5/20/2025, the LCD Hospice Eligibility Determination indicated that Patient 1 did not qualify per LCD guidelines. During a review of Patient 1’s Physician’s Certification for Hospice Benefit (also known as CTI or Certification of Terminal Illness, a document stating that a patient's medical prognosis indicates a life expectancy of six months or less if the illness runs its normal course, must be completed by a physician) for the certification period of 5/29/2025 to 7/27/2025 (certification #4), the physician narrative and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 1.During a joint home visit at Patient 1’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 11:20 a.m., Patient 1 was observed awake, alert, and oriented to person, place, and time (aware of his own identity, current location, and the current date and time). Patient 1 was observed walking independently without assistive device. Patient 1 was Spanish speaking.b.During a review of Patient 2’s Personal Information, the Personal Information indicated that Patient 2 was admitted to the HA on 10/1/2024 diagnosis that included acute on chronic combined systolic and diastolic heart failure (a condition where a patient with previously stable, chronic heart failure experiences a sudden worsening of symptoms, due to both systolic [pumping] and diastolic [filling] dysfunction) and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure.The last completed LCD Hospice Eligibility Determination for Patient 2 was dated 4/25/2025, for the certification period of . Patient 2 was currently in certification period #4, effective from 5/29/2025 to 7/27/2025.During a review of Patient 2’s Physician’s Certification for Hospice Benefit/CTI for the certification period of 5/29/2025 to 7/27/2025 (certification #4), the RN assessment narrative, physician narrative, and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 1.During a joint home visit at Patient 2’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 12:10 p.m., Patient 2 was observed awake, alert, and oriented to person, place, and time. Patient 2 is the wife of Patient 1. Patient 2 was Spanish speaking.  During an interview with Patient 1 and Patient 2 in their native language (Spanish) on 6/25/2025, at 12:48 p.m., Patient 1 stated he had never been informed by any of his physicians that he had a terminal illness and had a life expectation of 6 months or less. Patient 1 stated he was seen by his primary care physician (PCP, health care providers that offer routine checkups, vaccines, and non-emergency medical care) 10 days prior, and the physician did not mention terminal illness or hospice care. Patient 1 stated he had an upcoming appointment with his cardiologist a test, “to look at my arteries.” Patient 1 stated his cardiologist never told him that he was going to die in 6 months. During the same interview, Patient 2 denied having heart problems. Patient 2 stated she had respiratory issues, which were relieved with breathing treatments. Patient 2 stated she did not have a terminal illness. Patient 2 stated both she and Patient 1 routinely saw their doctors, and she believed if they were dying the doctors would have let them know. When Patient 1 and Patient 2 were asked if they were seen by the hospice agency’s physician, either in person or through a video call, both Patient 1 and Patient 2 stated they had never been seen by a physician from the hospice agency.During a telephone interview with Patient 2 on 6/27/2025 at 9:03 a.m., Patient 2 stated that her husband (Patient 1) was the one doing the grocery shopping, housekeeping, and cooking. Patient 2 stated she helped her husband as well with the household chores. c.During a review of Patient 3’s Personal Information, the Personal Information indicated that Patient 3 was admitted to the HA on 9/26/2024 diagnosis that included Alzheimer’s disease (a type of dementia that affects memory, thinking and behavior) with early onset and unspecified dementia (the loss of cognitive functioning – thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), severe, with anxiety. During a review of Patient 3’s LCD Hospice Eligibility Determination, dated 5/17/2025, the LCD Hospice Eligibility Determination indicated that Patient 3 did not qualify per LCD guidelines. During a review of Patient 3’s Physician’s Certification for Hospice Benefit/CTI for the certification period of 5/24/2025 to 7/22/2025, the physician narrative and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 3.d.During a review of Patient 6’s Personal Information, the Personal Information indicated that Patient 6 was admitted to the HA on 9/26/2024 diagnosis that included atherosclerotic heart disease of the native coronary artery with refractory angina pectoris (a condition where a person experiences chest pain [angina] due to narrowed coronary arteries caused by atherosclerosis [a condition where plaque, made up of cholesterol and other substances, builds up inside the arteries, narrowing them and reducing blood flow], and this pain persists despite optimal medical treatment) and overactive bladder. Patient 6 was discharged from the HA on 5/16/2025. During a review of Patient 6’s Physician’s Certification for Hospice Benefit/CTI for the certification period of 2/4/2025 to 4/4/2025 (certification #3), the RN assessment narrative, physician narrative, and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 6.During a review of Patient 6’s Physician’s Certification for Hospice Benefit/CTI for the certification period of 4/5/2025 to 6/3/2025 (certification #4), the physician narrative and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director. e.During a review of Patient 7’s Personal Information, the Personal Information indicated that Patient 7 was admitted to the HA on 6/24/2024 diagnosis that included acute combined systolic and diastolic heart failure and hypertensive heart disease with heart failure. Patent 7 was discharged from the HA on 12/10/2024. During a review of Patient 7’s Physician’s Certification for Hospice Benefit/CTI for the certification period of 9/22/2024 to 12/20/2024 (certification #2), the physician narrative and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 7.During a concurrent record review and interview with the Director of Patient Care Service (DPCS), on 6/26/2025 at 12:25 pm, the DPCS confirmed that the CTIs for Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14 were not completed. The DPCS stated the patients might not have been eligible for hospice if they were not recertified, as the patients’ condition might have changed. f. During a review of Patient 8’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 8’s start of care (SOC) date of 2/3/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery (blood vessels that supply blood to the heart muscle) without angina pectoris (a type of chest pain caused by reduced blood flow to the heart). During a review of Patient 8’s clinical record titled, Plan of Care (POC) Summary, the POC Summary indicated an order dated 2/3/2025, for the skilled nurse (SN) to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the registered nurse (RN) to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.    During a joint home visit at Patient 8’s residence, on 6/25/2025 at 11:00 a.m. with LVN 2, Patient 8 was observed awake, alert, oriented x 3 (to person, place, and time), ambulatory using a cane, and was independent of her care. Patient 8 was observed to have normal breathing, has no dyspnea (shortness of breath), and Patient 8 stated she did not have chest pain or discomfort. During an interview, on 6/25/2025, at 11:40 a.m., with Patient 8, Patient 8 stated that no one from the HA explained to her regarding what hospice care was, that she did not have terminal illness and was not dying, and that she signed up for hospice care because she was told by HA staff (unidentified) that they could supervise and check on her health condition, be visited by a nurse once a week to monitor her blood pressure, and can provide her with medical supplies and/or equipment. Patient 8 stated she was not referred by her own primary physician to hospice care, and that she never met, talked to or discussed her health condition/status with the hospice Medical Director. Patient 8 stated that she’s on medication for anxiety (a feeling of worry, nervousness, or fear) for years and would be more anxious and would feel helpless if she would lose hospice benefit in the future. During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS), the ADM/DPCS reviewed Patient 8’s Physician’s Certification for Hospice Benefit also known as Certification of Terminal Illness (CTI, a document required by Medicare and other payers to certify that a patient has a life expectancy of six months or less, assuming the illness runs its normal course) for certification #2 dated from 5/4/2025 to 8/1/2025. The ADM/DPCS stated and confirmed the CTI form was not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the CTI form was not signed by the doctor and no physician narrative was documented certifying Patient 8’s admission to hospice care. g. During a review of Patient 9’s Face Sheet, the face sheet indicated Patient 9’s SOC date of 12/3/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 8’s clinical record titled, POC Summary, the POC Summary indicated an order dated 12/3/2024, for the SN to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.    During a phone interview, on 6/25/2025, at 2:07 p.m., with Patient 9, Patient 9 stated that she was fully independent of her care, was still in the process of looking for a job, was not dying, does not have terminal illness, and that the HA staff did not explain to her what hospice care was. Patient 9 stated she was not referred by her own regular physician to hospice care, and that she never met, talked to or discussed her health condition/status with the hospice Medical Director. Patient 9 stated that it would be pretty bad if she will lose her hospice benefit in the future. During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 9’s CTI forms for certification #2 dated from 3/3/2025 to 5/31/2025, and for certification #3 from 6/1/2025 to 7/30/2025. The ADM/DPCS stated and confirmed the CTI forms for certification #2 and #3 were not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 9’s admission to hospice care. h. During a review of Patient 10’s Face Sheet, the face sheet indicated Patient 10’s SOC date of 2/11/2025, with a terminal diagnosis of hypertensive heart disease (refers to heart conditions that develop as a result of long-term high blood pressure) without heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).   During a review of Patient 10’s clinical record titled, POC Summary, the POC Summary indicated an order dated 2/11/2025, for the SN to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.    During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 10’s CTI form for certification #2 from 5/12/2025 to 8/9/2025. The ADM/DPCS stated and confirmed the CTI form was not signed by the Medical Director. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 10’s admission to hospice care. i. During a review of Patient 12’s Face Sheet, the face sheet indicated Patient 12’s SOC date of 1/10/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. During a review of Patient 12’s clinical record titled, POC Summary, the POC Summary indicated an order dated 1/10/2025, for the SN to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.    During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 12’s CTI form for certification #2 from 4/10/2025 to 7/8/2025. The ADM/DPCS stated and confirmed the CTI form was not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 12’s admission to hospice care. j. During a review of Patient 13’s Face Sheet, the face sheet indicated Patient 13’s SOC date of 4/17/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with refractory angina pectoris (a chronic and persistent form of angina, a type of chest pain caused by reduced blood flow to the heart). The face sheet further indicated Patient 13 was discharged from hospice service on 3/12/2025 due to extended prognosis. During a review of Patient 13’s clinical record titled, POC Summary, the POC Summary indicated an order dated 4/20/2024, for the SN to visit the patient twice a week to perform/train patient/patient caregiver(PCG)/family on pain management and symptom management, for the RN to visit every 14 days for supervisory visit, clinical care and support and recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days of admission.     During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 13’s CTI form for certification #6 from 1/12/2025 to 3/12/2025. The ADM/DPCS stated and confirmed the CTI form was not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 13’s admission to hospice care. k. During a review of Patient 14’s Face Sheet, the face sheet indicated Patient 14’s SOC date of 11/21/2024, with a terminal diagnosis of acute on chronic combined systolic and diastolic heart failure. The face sheet further indicated Patient 14 was discharged from hospice service on 5/24/2025. During a review of Patient 14’s clinical record titled, POC Summary, the POC Summary indicated an order dated 11/25/2024, for the SN to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.    During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 14’s CTI form for certification #2 from 2/19/2025 to 5/19/2025, and for certification #3 from 5/20/2025 to 7/18/2025. The ADM/DPCS stated and confirmed the CTI forms for certification #2 and certification #3  was not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 14’s admission to hospice care. During a phone interview with the hospice Medical Director, on 6/26/2025 at 12:03 p.m.,  the Medical Director stated he was responsible for certifying patient to hospice care and to document a completed CTI form including his signature. The Medical Director stated he was not aware Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14’s CTI forms was not completed and signed. The Medical Director stated that patients need to be recertified with a completed CTI form to ensure they are still appropriate to receive hospice services. During a review of the agency’s policy and procedure (P&P) titled Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluations, revised February 2021, the P&P indicated hospice will obtain appropriate certification and recertification of terminal illness. In order to be eligible to elect Hospice care under Medicare, a patient must be certified as being terminally ill. Hospice will obtain written certification of terminal illness for each of the periods listed, even if a single election continues for two, three or four periods. Hospice will obtain written certification no later than two (2) calendar days after the period begins. During a review of the agency’s Job Description Summary for the Hospice Medical Director, revised November 2020, the Job Description Summary indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The duties and responsibilities of the Medical Director will include, but not limited to, the following:-          Devoting his/her best ability to the proper management of the program-          Assuring that the established policies, bylaws, rules, and regulations of the organization are followed in the program-          Reviewing patients’ medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care written certification of terminal illness-          Providing written certification of terminal illness for all subsequent benefit periods.    Findings:a. During a review of Patient 1’s Personal Information, the Personal Information indicated Patient 1 was admitted to the HA on 10/1/2024 with diagnoses that included atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) without angina pectoris (chest pain caused by reduced blood flow to the heart muscle) and type 2 diabetes mellitus (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to elevated blood sugar levels).During a review of Patient 1’s Local Coverage Determination (LCD) Hospice Eligibility Determination (used by hospice providers to determine eligibility for beneficiaries of hospice benefits), dated 5/20/2025, the LCD Hospice Eligibility Determination indicated that Patient 1 did not qualify per LCD guidelines. During a review of Patient 1’s Physician’s Certification for Hospice Benefit (also known as CTI or Certification of Terminal Illness, a document stating that a patient's medical prognosis indicates a life expectancy of six months or less if the illness runs its normal course, must be completed by a physician) for the certification period of 5/29/2025 to 7/27/2025 (certification #4), the physician narrative and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 1.During a joint home visit at Patient 1’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 11:20 a.m., Patient 1 was observed awake, alert, and oriented to person, place, and time (aware of his own identity, current location, and the current date and time). Patient 1 was observed walking independently without assistive device. Patient 1 was Spanish speaking. b. During a review of Patient 2’s Personal Information, the Personal Information indicated Patient 2 was admitted to the HA on 10/1/2024 with diagnoses that included acute or chronic combined systolic and diastolic heart failure (a condition where a patient with previously stable, chronic heart failure experiences a sudden worsening of symptoms, due to both systolic [pumping] and diastolic [filling] dysfunction) and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure.During a review of Patient 2's LCD Hospice Eligibility Determination, last completed LCD Hospice Eligibility Determination was dated 4/25/2025, for the certification period of . Patient 2 was currently in certification period #4, effective from 5/29/2025 to 7/27/2025 and had no current LCD Hospice Eligibility Determination for certification period #4, effective from 5/29/2025 to 7/27/2025. During a review of Patient 2’s Physician’s Certification for Hospice Benefit/CTI for the certification period of 5/29/2025 to 7/27/2025 (certification #4), the RN assessment narrative, physician narrative, and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 1.During a joint home visit at Patient 2’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 12:10 p.m., Patient 2 was observed awake, alert, and oriented to person, place, and time. Patient 2 is the wife of Patient 1. Patient 2 was Spanish speaking. During an interview with Patient 1 and Patient 2 in their native language (Spanish) on 6/25/2025, at 12:48 p.m., at their home, Patient 1 stated he had never been informed by any of his physicians that he had a terminal illness and had a life expectation of 6 months or less. Patient 1 stated he was seen by his primary care physician (PCP, health care providers that offer routine checkups, vaccines, and non-emergency medical care) 10 days prior, and the physician did not mention terminal illness or hospice care. Patient 1 stated he had an upcoming appointment with his cardiologist a test, “to look at my arteries.” Patient 1 stated his cardiologist never told him that he was going to die in 6 months. During the same interview, Patient 2 denied having heart problems. Patient 2 stated she had respiratory issues, which were relieved with breathing treatments. Patient 2 stated she did not have a terminal illness. Patient 2 stated both she and Patient 1 routinely saw their doctors, and she believed if they were dying the doctors would have let them know. When Patient 1 and Patient 2 were asked if they were seen by the hospice agency’s physician, either in person or through a video call, both Patient 1 and Patient 2 stated they had never been seen by a physician from the hospice agency.During a telephone interview on 6/27/2025 at 9:03 a.m., with Patient 2 , Patient 2 stated that her husband (Patient 1) was the one doing the grocery shopping, housekeeping, and cooking. Patient 2 stated she helped her husband as well with the household chores.  c. During a review of Patient 3’s Personal Information, the Personal Information indicated Patient 3 was admitted to the HA on 9/26/2024 diagnosis that included Alzheimer’s disease (a type of dementia that affects memory, thinking and behavior) with early onset and unspecified dementia (the loss of cognitive functioning – thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities), severe, with anxiety. During a review of Patient 3’s LCD Hospice Eligibility Determination, dated 5/17/2025, the LCD Hospice Eligibility Determination indicated that Patient 3 did not qualify per LCD guidelines. During a review of Patient 3’s Physician’s Certification for Hospice Benefit/CTI for the certification period of 5/24/2025 to 7/22/2025, the physician narrative and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 3. d. During a review of Patient 6’s Personal Information, the Personal Information indicated Patient 6 was admitted to the HA on 9/26/2024 diagnosis that included atherosclerotic heart disease of the native coronary artery with refractory angina pectoris (a condition where a person experiences chest pain [angina] due to narrowed coronary arteries caused by atherosclerosis [a condition where plaque, made up of cholesterol and other substances, builds up inside the arteries, narrowing them and reducing blood flow], and this pain persists despite optimal medical treatment) and overactive bladder. Patient 6 was discharged from the HA on 5/16/2025. During a review of Patient 6’s Physician’s Certification for Hospice Benefit/CTI for the certification period of 2/4/2025 to 4/4/2025 (certification #3), the RN assessment narrative, physician narrative, and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 6.During a review of Patient 6’s Physician’s Certification for Hospice Benefit/CTI for the certification period of 4/5/2025 to 6/3/2025 (certification #4), the physician narrative and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director. e. During a review of Patient 7’s Personal Information, the Personal Information indicated Patient 7 was admitted to the HA on 6/24/2024 diagnosis that included acute combined systolic and diastolic heart failure and hypertensive heart disease with heart failure. Patent 7 was discharged from the HA on 12/10/2024. During a review of Patient 7’s Physician’s Certification for Hospice Benefit/CTI for the certification period of 9/22/2024 to 12/20/2024 (certification #2), the physician narrative and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 7.During a concurrent record review and interview with the Director of Patient Care Service (DPCS), on 6/26/2025 at 12:25 pm, the DPCS confirmed that the CTIs for Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14 were not completed. The DPCS stated the patients might not have been eligible for hospice if they were not recertified, as the patients’ condition might have changed. f. During a review of Patient 8’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 8’s start of care (SOC) date of 2/3/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery (blood vessels that supply blood to the heart muscle) without angina pectoris (a type of chest pain caused by reduced blood flow to the heart).During a review of Patient 8’s clinical record titled, Plan of Care (POC) Summary, the POC Summary indicated an order dated 2/3/2025, for the skilled nurse (SN) to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the registered nurse (RN) to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.   During a joint home visit at Patient 8’s residence, on 6/25/2025 at 11:00 a.m. with LVN 2, Patient 8 was observed awake, alert, oriented x 3 (to person, place, and time), ambulatory using a cane, and was independent of her care. Patient 8 was observed to have normal breathing, has no dyspnea (shortness of breath), and Patient 8 stated she did not have chest pain or discomfort.During an interview, on 6/25/2025, at 11:40 a.m., with Patient 8, Patient 8 stated that no one from the HA explained to her regarding what hospice care was, that she did not have terminal illness and was not dying, and that she signed up for hospice care because she was told by HA staff (unidentified) that they could supervise and check on her health condition, be visited by a nurse once a week to monitor her blood pressure, and can provide her with medical supplies and/or equipment. Patient 8 stated she was not referred by her own primary physician to hospice care, and that she never met, talked to or discussed her health condition/status with the hospice Medical Director. Patient 8 stated that she’s on medication for anxiety (a feeling of worry, nervousness, or fear) for years and would be more anxious and would feel helpless if she would lose hospice benefit in the future.During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS), the ADM/DPCS reviewed Patient 8’s Physician’s Certification for Hospice Benefit also known as Certification of Terminal Illness (CTI, a document required by Medicare and other payers to certify that a patient has a life expectancy of six months or less, assuming the illness runs its normal course) for certification #2 dated from 5/4/2025 to 8/1/2025. The ADM/DPCS stated and confirmed the CTI form was not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the CTI form was not signed by the doctor and no physician narrative was documented certifying Patient 8’s admission to hospice care. g. During a review of Patient 9’s Face Sheet, the face sheet indicated Patient 9’s SOC date of 12/3/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a review of Patient 8’s clinical record titled, POC Summary, the POC Summary indicated an order dated 12/3/2024, for the SN to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.  During a phone interview, on 6/25/2025, at 2:07 p.m., with Patient 9, Patient 9 stated, she (Patient 9) was fully independent of her care, was still in the process of looking for a job, was not dying, has no terminal illness, and the HA staff did not explain to her (Patient 9) what hospice care was. Patient 9 stated she (Patient 9) was not referred by her own regular physician to hospice care, and that she (Patient 9) never met, talked to or discussed her health condition/status with the hospice Medical Director. Patient 9 stated that it would be pretty bad if she (Patient 9) would lose her hospice benefit in the future.During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m., with the ADM/DPCS, the ADM/DPCS reviewed Patient 9’s CTI forms for certification #2 dated from 3/3/2025 to 5/31/2025, and for certification #3 from 6/1/2025 to 7/30/2025. The ADM/DPCS stated and confirmed the CTI forms for certification #2 and #3 were not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 9’s admission to hospice care. h. During a review of Patient 10’s Face Sheet, the face sheet indicated Patient 10’s SOC date of 2/11/2025, with a terminal diagnosis of hypertensive heart disease (refers to heart conditions that develop as a result of long-term high blood pressure) without heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).  During a review of Patient 10’s clinical record titled, POC Summary, the POC Summary indicated an order dated 2/11/2025, for the SN to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.   During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 10’s CTI form for certification #2 from 5/12/2025 to 8/9/2025. The ADM/DPCS stated and confirmed the CTI form was not signed by the Medical Director. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 10’s admission to hospice care. i. During a review of Patient 12’s Face Sheet, the face sheet indicated Patient 12’s SOC date of 1/10/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a review of Patient 12’s clinical record titled, POC Summary, the POC Summary indicated an order dated 1/10/2025, for the SN to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.   During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 12’s CTI form for certification #2 from 4/10/2025 to 7/8/2025. The ADM/DPCS stated and confirmed the CTI form was not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 12’s admission to hospice care. j. During a review of Patient 13’s Face Sheet, the face sheet indicated Patient 13’s SOC date of 4/17/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with refractory angina pectoris (a chronic and persistent form of angina, a type of chest pain caused by reduced blood flow to the heart). The face sheet further indicated Patient 13 was discharged from hospice service on 3/12/2025 due to extended prognosis.During a review of Patient 13’s clinical record titled, POC Summary, the POC Summary indicated an order dated 4/20/2024, for the SN to visit the patient twice a week to perform/train patient/patient caregiver(PCG)/family on pain management and symptom management, for the RN to visit every 14 days for supervisory visit, clinical care and support and recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days of admission.    During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 13’s CTI form for certification #6 from 1/12/2025 to 3/12/2025. The ADM/DPCS stated and confirmed the CTI form was not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 13’s admission to hospice care. k. During a review of Patient 14’s Face Sheet, the face sheet indicated Patient 14’s SOC date of 11/21/2024, with a terminal diagnosis of acute on chronic combined systolic and diastolic heart failure. The face sheet indicated Patient 14 was discharged from hospice service on 5/24/2025.During a review of Patient 14’s clinical record titled, POC Summary, the POC Summary indicated an order dated 11/25/2024, for the SN to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.   During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 14’s CTI form for certification #2 from 2/19/2025 to 5/19/2025, and for certification #3 from 5/20/2025 to 7/18/2025. The ADM/DPCS stated and confirmed the CTI forms for certification #2 and certification #3  was not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 14’s admission to hospice care. During a phone interview with the hospice agency's Medical Director, on 6/26/2025 at 12:03 p.m., the Medical Director (MD) stated he (MD) was responsible for certifying patient to hospice care and to document a completed CTI form including his (MD) signature. The MD stated he (MD) was not aware Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14’s CTI forms was not completed and signed. The Medical Director stated patients (in general) need to be recertified with a completed CTI form to ensure patients (in general) were appropriate to receive hospice services.During a review of the agency’s policy and procedure (P&P) titled Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluations, revised February 2021, the P&P indicated hospice will obtain appropriate certification and recertification of terminal illness. In order to be eligible to elect Hospice care under Medicare, a patient must be certified as being terminally ill. Hospice will obtain written certification of terminal illness for each of the periods listed, even if a single election continues for two, three or four periods. Hospice will obtain written certification no later than two (2) calendar days after the period begins.  During a review of the agency’s Job Description Summary for the Hospice Medical Director, revised November 2020, the Job Description Summary indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The duties and responsibilities of the Medical Director will include, but not limited to, the following:-          Devoting his/her best ability to the proper management of the program-          Assuring that the established policies, bylaws, rules, and regulations of the organization are followed in the program-          Reviewing patients’ medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care written certification of terminal illness-          Providing written certification of terminal illness for all subsequent benefit periods.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live), failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) for Clinical Records was met as follows: --- d. For Patient 8, who had a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of atherosclerotic heart disease of native coronary artery without angina pectoris, there was no recertification nursing comprehensive assessment documented for the current period, no current plan of care developed for pain management, fall/safety precautions and symptoms management, and the physician’s Certificate of Terminal Illness (CTI, a document required by Medicare and other payers to certify that a patient has a life expectancy of six months or less, assuming the illness runs its normal course) for certification #2 from 5/4/2025 to 8/1/2025 was unsigned. e. For Patient 9, who had a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, there was no recertification nursing comprehensive assessment documented for the current period, no current plan of care developed for respiratory care/management (anything related to respiration or how we breathe)) and bleeding precautions, and the physician’s CTI for certification #2 and #3 was unsigned.f. For Patient 10, who had a terminal illness of hypertensive heart disease without heart failure, the physician’s CTI for certification #2 from 5/12/2025 to 8/9/2025 was unsigned.g. For Patient 11, who had a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, there was no current plan of care developed for pain management, cardiovascular care (relating to the heart and blood vessels), and symptom management. h. For Patient 12, who had a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, the physician’s CTI for certification #2 from 4/10/2025 to 7/8/2025 was unsigned.i. For Patient 13, who had a terminal diagnosis of atherosclerotic heart disease of native coronary artery with refractory angina pectoris (a chronic and persistent form of angina, a type of chest pain caused by reduced blood flow to the heart), there was no care plan developed for pain management, cardiovascular care and symptom management, the physician’s CTI for certification #6  from 1/12/2025 to 3/12/2025 was unsigned, and discharge summary dated 3/12/2025 was not signed. j. For Patient 14, who had a terminal diagnosis of acute on chronic combined systolic and diastolic heart failure, there was no care plan for pain management, cardiovascular care and symptom management, the physician’s CTI for certification #2 from 2/19/2025 to 5/19/2025 was unsigned, and discharge summary dated 5/24/2025 was not signed. As a result, Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 did not have completed clinical records that could potentially not identify a change in patients’ conditions and affect the patients’ care and services that could lead to hospitalization and death. (Refer to L672) The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (decided and controlled by law) mandated compliance with the Federal Regulations for Clinical Records to ensure provision of quality care and services to patients.      1. The hospice agency failed to ensure the clinical records of ten of fourteen sampled patients (Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) included the plan of care, assessments, comprehensive assessments, and clinical notes that reflected the patients’ current health status. (Refer to L672).a. For Patient 1, who had diagnosis that included atherosclerotic heart   disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) without angina pectoris (chest pain caused by reduced blood flow to the heart muscle) and type 2 diabetes mellitus (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to elevated blood sugar levels), there was no plan of care developed, no recertification assessment for the current certification period, and no skilled nurse (SN, licensed nurse in general) visit notes for the completed visits.b. For Patient 2, who had diagnosis that included acute on chronic combined systolic and diastolic heart failure (a condition where a patient with previously stable, chronic heart failure experiences a sudden worsening of symptoms, due to both systolic [pumping] and diastolic [filling] dysfunction) and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure, there was no plan of care developed, no recertification assessment for the current certification period, and no SN visit notes for the completed visits.c. For Patient 7, who had diagnosis that included acute combined systolic and diastolic heart failure and hypertensive heart disease with heart failure, there was no plan of care developed.d. For Patient 8e. For Patient 9f. For Patient 10g. For Patient 11h. For Patient 12i. For Patient 13j. For Patient 14 As a result, Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 did not have completed clinical records that could potentially not identify a change in patients’ conditions and affect the patients’ care and services that could lead to hospitalization and death.The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with the federal regulations for Clinical Records to ensure provision of quality care and services to patients.

Based on interview and record review, the HA failed to ensure the clinical records (systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction) of ten of fourteen sampled patients (Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) included the plan of care, assessments, comprehensive assessments, and clinical notes that reflected the patients’ current health status. a. For Patient 1, who had diagnosis that included atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) without angina pectoris (chest pain caused by reduced blood flow to the heart muscle) and type 2 diabetes mellitus (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to elevated blood sugar levels), there was no documentation of plan of care developed, no records of  recertification assessment for the current certification period, and no record of skilled nurse (SN, licensed nurse in general) visit notes for the completed visits.b. For Patient 2, who had diagnosis that included acute on chronic combined systolic and diastolic heart failure (a condition where a patient with previously stable, chronic heart failure experiences a sudden worsening of symptoms, due to both systolic [pumping] and diastolic [filling] dysfunction) and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure, there was no record of documentation of plan of care developed, no record of recertification assessment for the current certification period, and no documentation of SN visit notes for the completed visits.c. For Patient 7, who had diagnosis that included acute combined systolic and diastolic heart failure and hypertensive heart disease with heart failure, there was no documentation of plan of care developed.d. For Patient 8, who had a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of atherosclerotic heart disease of native coronary artery without angina pectoris, there was no record of  recertification nursing comprehensive assessment documented for the current period, no record of current plan of care developed for pain management, fall/safety precautions and symptoms management, and the physician’s Certificate of Terminal Illness (CTI, a document required by Medicare and other payers to certify that a patient has a life expectancy of six months or less, assuming the illness runs its normal course) for certification #2 from 5/4/2025 to 8/1/2025 was unsigned. e. For Patient 9, who had a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, there was no record of recertification nursing comprehensive assessment documented for the current period, no documentation of current plan of care developed for respiratory care/management (anything related to respiration or how we breathe)) and bleeding precautions, and the physician’s CTI for certification #2 and #3 was unsigned.f. For Patient 10, who had a terminal illness of hypertensive heart disease without heart failure, the physician’s CTI for certification #2 from 5/12/2025 to 8/9/2025 was not signed by the physician. g. For Patient 11, who had a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, there was no documentation of current plan of care developed for pain management, cardiovascular care (relating to the heart and blood vessels), and symptom management. h. For Patient 12, who had a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, the physician’s CTI for certification #2 from 4/10/2025 to 7/8/2025 was not signed by the physician. i. For Patient 13, who had a terminal diagnosis of atherosclerotic heart disease of native coronary artery with refractory angina pectoris (a chronic and persistent form of angina, a type of chest pain caused by reduced blood flow to the heart), there was no documentation of care plan developed for pain management, cardiovascular care and symptom management, the physician’s CTI for certification #6  from 1/12/2025 to 3/12/2025 was not signed, and discharge summary dated 3/12/2025 was not signed. j. For Patient 14, who had a terminal diagnosis of acute on chronic combined systolic and diastolic heart failure, there was no documentation of care plan for pain management, cardiovascular care and symptom management, the physician’s CTI for certification #2 from 2/19/2025 to 5/19/2025 was unsigned, and discharge summary dated 5/24/2025 was not signed. As a result, Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 did not have completed clinical records that could potentially not identify a change in patients’ conditions and affect the patients’ care and services that could lead to hospitalization and death. On 6/27/2025, at 2:34 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facility’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called in the presence of the agency’s Administrator/Director of Patient Care Services (ADM/DPCS) related to the agency’s failure to ensure that each patient’s clinical records were complete and included the initial plan of care, updated plan of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes.On 6/27/2025, at 3:50 p.m., the HA was unable to submit an IJ removal plan (includes all actions the agency has taken or will take to immediately address the noncompliance that resulted in or made serious injury, serious harm, serious impairment, or death likely).On 6/27/2024, at 4:00 p.m., the survey team completed the survey tasks and conducted an exit conference in the presence of the ADM/DPCS and Office Manager, with the IJ not removed. --- d. During a review of Patient 8’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 8’s start of care (SOC) date of 2/3/2025, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of atherosclerotic heart disease of native coronary artery without angina pectoris.During a review of Patient 8’s electronic health record (EHR) on 6/25/2025, the EHR indicated there was no individualized plan of care developed at all for Patient 8 for the current certification period effective date from 5/4/2025 to 8/1/2025.During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS), the ADM/DPCS reviewed Patient 8’s Physician’s Certification for Hospice Benefit also known as Certification of Terminal Illness (CTI, a document required by Medicare and other payers to certify that a patient has a life expectancy of six months or less, assuming the illness runs its normal course) for certification #2 dated from 5/4/2025 to 8/1/2025. The ADM/DPCS stated and confirmed the CTI form was not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the CTI form was not signed by the doctor and no physician narrative was documented certifying Patient 8’s admission to hospice care.During a concurrent interview and record review, on 6/27/2025 at 11:45 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 8’s clinical record titled, History of Nursing Assessment. The ADM/DPCS stated and confirmed there was no Comprehensive Recertification Assessment conducted for Patient 8 for the current certification period from 5/4/2025 to 8/1/2025. The ADM/DPCS stated the purpose of the comprehensive assessment was to evaluate the patients’ need, the overall condition and his or her current health status to continue hospice care and should have been conducted within 5 days of the new certification period. The ADM/DPCS further stated that without the assessment, the agency staff would not know patient needs and what to care for related to the patient’s terminal illness. e. During a review of Patient 9’s Face Sheet, the face sheet indicated Patient 9’s SOC date of 12/3/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a review of Patient 9’s EHR on 6/25/2025, the EHR indicated there was no individualized plan of care developed at all for Patient 9 for the current certification period effective date from 6/1/2025 to 7/30/2025.During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 9’s CTI forms for certification #2 dated from 3/3/2025 to 5/31/2025, and for certification #3 from 6/1/2025 to 7/30/2025. The ADM/DPCS stated and confirmed the CTI forms for certification #2 and #3 were not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 9’s admission to hospice care.During a concurrent interview and record review, on 6/27/2025 at 11:45 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 9’s clinical record titled, History of Nursing Assessment. The ADM/DPCS stated and confirmed there was no Comprehensive Recertification Assessment conducted for Patient 9 for the certification period starting from 3/3/2025 to 5/31/2025 and for the current certification period from 6/1/2025 to 7/30/2025. The ADM/DPCS stated the purpose of the comprehensive assessment was to evaluate the patients’ need, the overall condition and his or her current health status to continue hospice care and should have been conducted within 5 days of the new certification period. The ADM/DPCS further stated that without the assessment, the agency staff would not know patient needs and what to care for related to the patient’s terminal illness. f. During a review of Patient 10’s Face Sheet, the face sheet indicated Patient 10’s SOC date of 2/11/2025, with a terminal diagnosis of hypertensive heart disease without heart failure.  During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 10’s CTI form for certification #2 from 5/12/2025 to 8/9/2025. The ADM/DPCS stated and confirmed the CTI form was not signed by the Medical Director. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 10’s admission to hospice care. g. During a review of Patient 11’s Face Sheet, the face sheet indicated Patient 11’s SOC date of 4/3/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a review of Patient 11’s EHR on 6/25/2025, the EHR indicated there was no current plan of care developed for cardiovascular care, pain management, and symptom management related to terminal illness diagnosis for Patient 11. h. During a review of Patient 12’s Face Sheet, the face sheet indicated Patient 12’s SOC date of 1/10/2025, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris.During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 12’s CTI form for certification #2 from 4/10/2025 to 7/8/2025. The ADM/DPCS stated and confirmed the CTI form was not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 12’s admission to hospice care. i. During a review of Patient 13’s Face Sheet, the face sheet indicated Patient 13’s SOC date of 4/17/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with refractory angina pectoris (a chronic and persistent form of angina, a type of chest pain caused by reduced blood flow to the heart). The face sheet further indicated Patient 13 was discharged from hospice service on 3/12/2025 due to extended prognosis.During a review of Patient 13’s EHR on 6/25/2025, the EHR indicated there was no individualized plan of care developed at all for Patient 13 for the most recent certification period effective date from 1/12/2025 to 3/12/2025.During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 13’s CTI form for certification #6 from 1/12/2025 to 3/12/2025. The ADM/DPCS stated and confirmed the CTI form was not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 13’s admission to hospice care.During a concurrent interview and record review, on 6/27/2025 at 1:30 p.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 13’s discharge summary form (D/C summary) dated 3/12/2025. The ADM/DPCS stated Patient 13 was discharged on 3/12/2025 due to her extended prognosis (the likely course of a disease). The ADM/DPCS stated and confirmed the D/C summary was not signed by the documenting nurse. The ADM/DPCS stated if a clinical record was not signed, it was considered as if the patient encounter did not occur. The ADM/DPCS stated all clinical records should be signed and dated by the hospice staff to validate accuracy and responsibility for the information documented. j. During a review of Patient 14’s Face Sheet, the face sheet indicated Patient 14’s SOC date of 11/21/2024, with a terminal diagnosis of acute on chronic combined systolic and diastolic heart failure. The face sheet further indicated Patient 14 was discharged from hospice service on 5/24/2025.During a review of Patient 14’s EHR on 6/25/2025, the EHR indicated there was no individualized plan of care developed at all for Patient 14 for the last two most recent certification period effective date from 2/19/2025 to 5/19/2025, and effective date from 5/20/2025 to 7/18/2025.During a concurrent interview and record review, on 6/26/2025 at 11:35 a.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 14’s CTI form for certification #2 from 2/19/2025 to 5/19/2025, and for certification #3 from 5/20/2025 to 7/18/2025. The ADM/DPCS stated and confirmed the CTI forms for certification #2 and certification #3 was not signed by the Medical Director and there was no documentation under the section, “Certifying Physician Narrative”. The ADM/DPCS stated the CTI form was a very important document to justify that patients are qualified for hospice care and should have been signed and completed by the Medical Director. The ADM/DPCS stated that it was a mistake that the form was not signed by the doctor and no physician narrative was documented certifying Patient 14’s admission to hospice care.During a concurrent interview and record review, on 6/27/2025 at 1:30 p.m. with the ADM/DPCS, the ADM/DPCS reviewed Patient 14’s D/C summary dated 5/24/2025. The ADM/DPCS stated Patient 14 was discharged on 5/24/2025. The ADM/DPCS stated and confirmed the D/C summary was not signed by the documenting nurse. The ADM/DPCS stated if a clinical record was not signed, it was considered as if the patient encounter did not occur. The ADM/DPCS stated all clinical records should be signed and dated by the hospice staff to validate accuracy and responsibility for the information documented.During a review of the HA’s policy and procedure (P&P), titled Patient Record Content, revised June 2019, the P&P indicated hospice will provide an accurate and current patient record for every patient seen by hospice. The record, whether hard copy or in electronic form, will be made readily available on request by an appropriate authority. All entries must be legible, clear, complete and appropriately authenticated. Each patient record will contain the following as applicable:-         Certification and recertification of terminal illness statements-         Comprehensive assessment-         Updates to the comprehensive assessment-         Care/services provided by hospice, including contracted staff-         Date care/services provided and staff/title who provided care/services-         Initial interdisciplinary group (IDG) care plan-         Review and revision of the IDG care plan-         Physician narrative statement and face-to-face encounters-         A discharge summary when patient is discharged from hospiceDuring a review of the agency’s P&P titled Initial Assessment/Comprehensive Assessment, revised February 2021, the P&P indicated each patient admitted by Hospice will have an appropriate initial assessment and comprehensive assessment performed and documented which promote the patient's well-being, comfort and dignity throughout the dying process. The comprehensive assessment will identify the patient’s need for hospice care and identify the patient’s need for physical care, psychosocial and emotional care, spiritual care, and all areas of hospice care related to the palliation and management of the terminal illness and related conditions.During a review of the agency’s P&P titled Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluations, revised February 2021, the P&P indicated hospice will obtain appropriate certification and recertification of terminal illness. In order to be eligible to elect Hospice care under Medicare, a patient must be certified as being terminally ill. Hospice will obtain written certification of terminal illness for each of the periods listed, even if a single election continues for two, three or four periods. Hospice will obtain written certification no later than two (2) calendar days after the period begins.During a review of the HA’s P&P titled IDG Care Planning Process, revised February 2021, the P&P indicated that the care of plan specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions. The P&P further indicated that all care and services furnished to patients and their families follows an individualized written plan of care established by the IDG in collaboration with the attending physician (if any), the patient, or representative and the primary caregiver in accordance with the patient’s needs. An individualized written plan of care is developed for each patient. The plan of care reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive and updated comprehensive assessments.    a.During a review of Patient 1’s Personal Information, the Personal Information indicated that Patient 1 was admitted to the HA on 10/1/2024 diagnosis that included atherosclerotic heart disease of native coronary artery (a specific type of cardiovascular disease that affects the arteries supplying blood to the heart muscle) without angina pectoris (chest pain caused by reduced blood flow to the heart muscle) and type 2 diabetes mellitus (a chronic metabolic disorder where the body either doesn't produce enough insulin or can't effectively use the insulin it produces, leading to elevated blood sugar levels).During a review of Patient 1’s electronic health record on 6/24/2025, there was no recertification assessment for the current certification period, effective from 5/29/2025 to 7/27/2025. There was also no individualized plan of care developed for Patient 1 for the current certification period. As a result, there were no interventions to manage Patient 1’s diabetes and monitor his blood sugar levels. During a review of Patient 1’s electronic health record on 6/27/2025, there was a recertification assessment for Patient 1 for the certification period of 5/20/2025 to 7/27/2025. The recertification assessment was dated 5/20/2025.During a review of Audit Log for Patient 1 on 6/27/2025, for Nursing Assessment module, the Audit Log indicated that the recertification assessment for Patient 1, dated 5/20/2025, was created on 6/26/2025 at 4:48 p.m. by the DPCS.During a concurrent interview and record review with the DPCS on 6/27/2025 at 11:09 a.m., the DPCS stated she had just documented Patient 1’s recert assessment on 6/26/2025. During a review of Patient 1’s electronic health record on 6/24/2025, Patient 1’s History of Visit Notes indicated the last four Skilled Nurse (SN, licensed nurse in general) visits were on 2/28/2025, 4/9/2025, 4/27/2025, and 6/13/2025.During an interview with the DPCS on 6/26/2025 at 11:04 a.m., the DPCS stated the frequency of SN visit for Patient 1 was once per week. On 6/27/2025, during a review of Hospice Visit Log for Patient 1, the Hospice Visit Log indicated that Patient 1 had SN visits on 3/12/2025, 3/20/2025, 3/26/2025, 3/31/2025, 4/9/2025, 4/27/2025, 5/3/2025, 5/11/2025, 5/24/2025 and 6/5/2025.b.During a review of Patient 2’s Personal Information, the Personal Information indicated that Patient 2 was admitted to the HA on 10/1/2024 diagnosis that included acute on chronic combined systolic and diastolic heart failure (a condition where a patient with previously stable, chronic heart failure experiences a sudden worsening of symptoms, due to both systolic [pumping] and diastolic [filling] dysfunction) and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure. During a review of Patient 2’s electronic health record on 6/24/2025, there was no recertification assessment for the current certification period, effective from 5/29/2025 to 7/27/2025. There was also no individualized plan of care developed for Patient 2 for the current certification period. As a result, there were no interventions to manage Patient 2’s hypertension and monitor her blood pressure levels.During a review of Patient 2’s electronic health record on 6/27/2025, there was a recertification assessment for Patient 2 for the certification period of 5/20/2025 to 7/27/2025. The recertification assessment was dated 5/25/2025.During a review of Audit Log for Patient 2 on 6/27/2025, for Nursing Assessment module, the Audit Log indicated that the recertification assessment for Patient 2, dated 5/25/2025, was created on 6/24/2025 at 4:20 p.m. by Nurse Practitioner 1 (NP 1). During a concurrent record review and interview with the DPCS on 6/27/2025 at 11:09 a.m., the DPCS stated that NP 1 had just documented Patient 2’s  recert assessment on 6/24/2025. The DPCS stated, “NP 1 is very busy.”During a review of Patient 2’s electronic health record on 6/24/2025, Patient 2’s History of Visit Notes indicated the last four SN visits were on 2/28/2025, 4/9/2025, 4/27/2025, and 6/13/2025.On 6/27/2025, during a review of Hospice Visit Log for Patient 2, the Hospice Visit Log indicated that Patient 2 had SN visits on 3/12/2025, 3/20/2025, 3/26/2025, 3/31/2025, 4/9/2025, 4/27/2025, 5/3/2025, 5/11/2025, 5/24/2025 and 6/5/2025. According to the DPCS, the HA used the Hospice Visit Log as a basis to pay the staff who conducted the visit for a patient. During an interview on 6/27/2025 at 11:36 p.m., the DPCS stated the nurses did not document the visits done for Patient 1 and Patient 2. The DPCS stated the lack of complete and accurate clinical records could affect the patient negatively, such as the physician and other health professionals involved were not aware of the patient’s current health status.  c.During a review of Patient 7’s Personal Information, the Personal Information indicated that Patient 7 was admitted to the HA on 6/24/2024 diagnosis that included acute combined systolic and diastolic heart failure and hypertensive heart disease with heart failure. Patent 7 was discharged from the HA on 12/10/2024. During a review of Patient 7’s electronic health record on 6/24/2025, there was no individualized plan of care developed for Patient 7 for the most recent certification period prior to discharge, effective from 9/22/2024 to 12/20/2024.During an interview with the DPCS on 6/26/2025 at 10:52 a.m., the DPCS stated that she was aware that Patient 1, Patient 2, Patient 7, Patient 8, Patient 9, Patient 11, Patient 13, and Patient 14 did not have an updated plan of care for months. The DPCS stated the plan of care needed to be updated at least every 2 weeks because patients’ condition might have changed, and the IDG members needed to address it. The DPCS stated, “It’s horrible that these patients don’t have a plan of care.”During an interview with the DPCS on 6/27/2025, at 1:06 p.m., the DPCS was asked how the staff knew what each patient’s problems were, what interventions they needed to provide, and what the goals were for each patient, when the patients did not have a care plan in place and assessments were not documented, the DPCS stated the HA staff had a group text where they would exchange information about the patients. The DPCS stated that a group text was not considered patient’s records and did not substitute clinical records. During a review of the HA’s policy and procedure (P & P), titled “Patient Record Content,” revised June 2019, the P & P indicated that some of the components of each patient record were as follows:-         Comprehensive assessment-         Updates to the comprehensive assessment-         Care/services provided by hospice, including contracted staff-         Date care/services provided and staff/title who provided care/services-         Initial interdisciplinary group (IDG) care plan-         Review and revision of the DIG care plan-         Physician narrative statement and face-to-face encounters

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the contents of the clinical records were protected from any modifications (making partial or minor changes) by facility personnel outside their assigned roles for one of fourteen sampled patients (Patient 2). This deficient practice had the potential for clinical records to contain inaccurate information, which could affect the formulation of patient's Plan of Care (POC, a document  detailing a patient’s health needs, created by a healthcare team based on a comprehensive assessment of the patient’s condition and goals, outlining interventions and expected outcomes to be achieved), interventions, and quality of care and services provided to patient. --- During a review of Patient 2’s Personal Information, the Personal Information indicated that Patient 2 was admitted to the HA on 10/1/2024 diagnosis that included acute on chronic combined systolic and diastolic heart failure (a condition where a patient with previously stable, chronic heart failure experiences a sudden worsening of symptoms, due to both systolic [pumping] and diastolic [filling] dysfunction) and hypertensive heart disease (heart conditions that develop as a result of long-term high blood pressure [hypertension]) with heart failure.The last completed LCD Hospice Eligibility Determination for Patient 2 was dated 4/25/2025, for the certification period of . Patient 2 was currently in certification period #4, effective from 5/29/2025 to 7/27/2025.During a review of Patient 2’s Physician’s Certification for Hospice Benefit/CTI for the certification period of 5/29/2025 to 7/27/2025 (certification #4), the RN assessment narrative, physician narrative, and certifying physician narrative sections were blank. The CTI was not signed by the Medical Director, whose name was listed as the hospice physician for Patient 2.During a joint home visit at Patient 2’s residence with Licensed Vocational Nurse 1 (LVN 1) on 6/25/2025 at 12:10 p.m., Patient 2 was observed awake, alert, and oriented to person, place, and time (aware of her own identity, current location, and the current date and time). Patient 2 was Spanish speaking.During the same interview, Patient 2 denied having heart problems. Patient 2 stated she had respiratory issues, which were relieved with breathing treatments. Patient 2 stated she did not have a terminal illness. Patient 2 stated both she and her husband (who was also a patient of the HA) routinely saw their doctors, and she believed if they were dying the doctors would have let them know. When Patient 2 and her husband were asked if they were seen by the hospice agency’s physician, either in person or through a video call, both stated they had never been seen by a physician from the hospice agency.During a phone interview with the hospice Medical Director, on 6/26/2025 at 12:03 p.m., stated he had access to the electronic health record used by the HA. The Medical Director stated he himself always documented and signed his own assessment of the patients. The Medical Director stated he had never asked another staff member to document on behalf of him. The Medical Director stated he had never shared his username and password with another staff member. During a review of Patient 2’s electronic health record on 6/27/2025, it was noted the physician narrative summary/certifying physician narrative summary sections of Patient 2’s CTI, for the certification period of 5/29/2025 to 7/27/2025 (certification #4), was completed. The CTI was not signed by the HA’s Medical Director.On 6/27/2025, during a review of Patient’s 2 Audit Log for Certification MD module, from 1/1/2025 to 6/26/2025, the Audit Log indicated that on 6/25/2025, at 8:11 a.m., the Director of Patient Care Services (DPCS) made modification to the Physician Narrative: Certifying Physician Summary section of the CTI. The DPCS input the following information for Patient 2: “Given my clinical findings, the patient meets the Medicare criteria for hospice care, that the patient is terminally ill with the prognosis of six months or less and it is recommended that the patient be recertified with hospice services.”During a concurrent interview and record review with the DPCS on 6/27/2025, at 1:17 p.m., the DPCS reviewed Patient 2’s Audit Log for Certification MD module, from 1/1/2025 to 6/26/2025. The DPCS acknowledged she entered the information under the physician credential. The DPCS stated she was not a physician. The DPCS stated the certifying physician summary should only be completed by the hospice’s physician or physician designee. The DPCS stated, “This is a mistake, a horrible mistake.” During a review of the HA’s policy and procedure (P & P), titled “Patient Record Entries: Authentication,” revised June 2019, the P & P indicated that all patient record entries would be dated and authenticated. Only authorized individuals make entries in the patient’s record. All entries in the patient record would be authenticated by staff by signing first name or initial, last name, and title. By authenticating entries in the patient’s record, staff is validating the correctness of the information.

Based on interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure a complete discharge summary was created upon discharge for 2 of 4 sampled discharged patients (Patient 13 and Patient 14).  This deficient practice had the potential to result in miscommunication and poor hand-off and can affect the care and services needed in the continuation of care for the affected patient. --- a. During a review of Patient 13’s Face Sheet (front page of the chart that contains a summary of basic information about the patient), the face sheet indicated Patient 13’s start of care (SOC) date of 4/17/2024, with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of atherosclerotic heart disease (a build-up of cholesterol plaque in the walls of arteries causing obstruction of blood flow) of native coronary artery (blood vessels that supply blood to the heart muscle) with refractory angina pectoris (a chronic and persistent form of angina, a type of chest pain caused by reduced blood flow to the heart). The face sheet further indicated Patient 13 was discharged from hospice service on 3/12/2025 due to extended prognosis.During a review of Patient 13’s clinical record titled, POC (Plan of Care) Summary, the POC Summary indicated an order dated 4/20/2024, for the SN to visit the patient twice a week to perform/train patient/patient caregiver(PCG)/family on pain management and symptom management, for the RN to visit every 14 days for supervisory visit, clinical care and support and recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days of admission.    During a review of Patient 13’s Discharge Summary (D/C) form, the D/C form indicated an End of Care (EOC) date of 3/12/2025, due to extended prognosis. The discharge summary was not signed by the documenting nurse.  b. During a review of Patient 14’s Face Sheet, the face sheet indicated Patient 14’s SOC date of 11/21/2024, with a terminal diagnosis of acute on chronic combined systolic and diastolic heart failure (a condition where a patient with a pre-existing, long-term heart condition experiences a sudden worsening of symptoms, affecting both the heart's ability to pump and relax/fill). The face sheet further indicated Patient 14 was discharged from hospice service on 5/24/2025.During a review of Patient 14’s clinical record titled, POC Summary, indicated an order dated 11/25/2024, for the SN to visit the patient once a week for assessments, clinical care, and support for ongoing evaluation of patient’s condition, for the RN to visit every 30 days for supervisory visit, recertification assessment per schedule for skilled assessment and intervention, and for the medical social worker and spiritual counselor to conduct an initial evaluation within 5 days from admission, recertification and as needed.   During a review of Patient 14’s D/C form, indicated an EOC date of 5/24/2025, due to patient’s moved out of the service area. The discharge summary was not signed by the documenting nurse.During a concurrent interview and record review, on 6/27/2025 at 1:30 p.m., with the Administrator/Director of Patient Care Services (ADM/DPCS), the ADM/DPCS reviewed Patient 13’s D/C form dated 3/12/2025, and Patient 14’s D/C form dated 5/24/2025. The ADM/DPCS stated Patient 13 was discharged on 3/12/2025 due to her extended prognosis (the likely course of a disease), and Patient 14 was discharged on 5/24/2025. The ADM/DPCS stated and confirmed the D/C summary for Patient 13 and Patient 14 were not signed by the documenting nurse. The ADM/DPCS stated if a clinical record was not signed, it was considered as if the patient encounter did not occur. The ADM/DPCS stated all clinical records should be signed and dated by the hospice staff to validate accuracy and responsibility for the information documented. During a review of the agency's policy and procedure (P&P), titled Discharge Summary, revised June 2019, the P&P indicated a discharge summary will be completed for patients as required by law and regulation. During a review of the HA’s P&P, titled Patient Record Content, revised June 2019, the P&P indicated hospice will provide an accurate and current patient record for every patient seen by hospice. The record, whether hard copy or in electronic form, will be made readily available on request by an appropriate authority. All entries must be legible, clear, complete and appropriately authenticated. Each patient record will contain the following as applicable: - Certification and recertification of terminal illness statements- Comprehensive assessment- Updates to the comprehensive assessment- Care/services provided by hospice, including contracted staff- Date care/services provided and staff/title who provided care/services- Initial interdisciplinary group (IDG) care plan- Review and revision of the IDG care plan- Physician narrative statement and face-to-face encounters- A discharge summary when patient is discharged from hospice

Upon patient record review 2 of 5 (Patients #1, #3) 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. Patients 1 and 3: Patient declined Spiritual Care. There was no evidence of a Spiritual Care assessment.

Upon patient record review, 1 of 5 (Patient #1) 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: There is an order dated 8/22/2022 Miralax 17GMs packet/pouch orally 2x day for no BM. There was no evidence of a diluent. Corrected on site.

Upon patient record review, 1 of 5 records (Patient #1) 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 medications and treatments. Patient 1: There is an order on the POC dated 8/22/2022 Miralax 17GMs packet/pouch orally 2x day for no BM. There was no evidence of a diluent. Corrected on site.

Upon client record review, 2 of 5 (Patient #1 and 5) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient 1: On SOC POC MSW ordered 1x month visits. There was no order decreasing visits or a missed visit note. There was no evidence of a MSW visit during the month of August. Patient 5: On SOC POC SN ordered 2x week. Through out entire episode of care 4/9/2022-5/18/2022 Patient received one RN visit per week. There was no evidence of an order to decreased visits, nor any documentation of missed visits.