Every finding on record at Aventus Hospice, Inc

Based on observation, interview, and record review, the Hospice Agency (HA, an 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 Patients Rights was met as follows: --- Findings: 1. The Hospice Agency failed to ensure patients' rights to be informed of the services the HA provides and the limitations of these services for five out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, and Patient 9) certified to receive hospice care and services. (Refer to L 519). The cumulative effect of this systemic practice resulted in the failure of the hospice agency to deliver statutorily mandated Federal compliance for Patients Rights to ensure their rights were not violated and patients received the highest quality of hospice care.

Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure patients rights to be informed of the services the HA provides and the limitations of these services for five out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 8, and Patient 9) certified to receive hospice care and services. This deficient practice resulted in the patients' rights being violated for not being fully informed about the purpose of the hospice care services and its limitations. --- d. A review of Patient 8s admission record indicated a start of care date of 11/14/2023 with a terminal diagnosis of acute ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 8s IDG/POC form, dated 11/17/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 90 days and as needed for five days for change in health status. On 11/30/2023 at 11 a.m., a joint home visit was conducted with Registered Nurse (RN 2) at Patient 8s home residence. Patient 8 was alert and oriented and well groomed. Patient 8 was asked if able to eat herself and stated that she was able to eat, and able to go to the bathroom and get out of bed by herself with the use of her cane. Patient 8 was also asked if she had a terminal illness or if she was dying stated, she was not dying and enrolled in hospice because she needed more information about her medical situation. During a telephone interview on 11/30/2023, at 4:06 p.m., Patient 8 stated she had a primary physician (PP 1) and was referred to hospice from a ";friend of a friend." During a telephone interview on 11/30/2023, at 4:15 p.m., Primary Physician (PP 1) stated he was the primary care doctor for Patient 8. PP 1 stated that he was not aware Patient 8 was on hospice and did not refer Patient 8 for hospice evaluation. PP1 further stated that Patient 8 does not have a terminal illness and was not eligible for hospice. e. A review of Patient 9s admission record indicated a start of care date of 4/2/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 9s IDG/POC form dated 11/3/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 60 days. During a telephone interview on 11/30/2023 at 3:33 p.m., Family Member 1 (FM 1) stated that she takes care of Patient 9. FM 1 further stated that she was also enrolled in hospice with Patient 9. FM 1 stated that a lady from her church referred both her and Patient 9 to hospice care services. Patient 9 was asked if she had terminal illness and could die within six months, FM 1 stated that both her and Patient 9 did not have a terminal illness and were not going to die within six months. There was no documented evidence FM1, and Patient 9 were informed in advance of the hospice care to be furnished, the organizations scope of services and services under the Medicare Hospice Benefit and any limitations on these services. During a review of the agencys undated policy and procedure titled, ";Patient Bill of Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. The Patient Bill of Rights/Responsibilities statement defines the right of the patient to be informed in advance of service about the care to be furnished, the organizations scope of services and services under the Medicate Hospice Benefit and any limitations on these services. Findings: a. A review of Patient 1s admission record indicated a start of care (SOC) date of 11/6/23 with a terminal diagnosis of acute ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 11/17/23, indicated the frequency of visits of licensed vocational nurse (LVN) to one to two visit per week, registered nurse (RN) to conduct initial evaluation within 5 days of admission then every recertification. During a joint home visit on 11/30/23, at 11:51 a.m., with LVN 1 at Patient 1s residence, Patient 1 was observed walking steadily at the living room without using an assistive device. During an interview on 11/30/23, at 12 p.m., Patient 1 was asked if she was informed about the purpose of the hospice care services and stated she was never told she had six months or less to live. Patient 1 stated a nurse from the agency would come visit every week to take her blood pressure readings. Patient 1 further stated she never had an attending physician and her friend referred her to the hospice agency. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 11/13/23 with a terminal diagnosis of atherosclerotic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 11/17/23, indicated the frequency of visits of licensed vocational nurse (LVN) to one to two visit per week, to conduct initial evaluation within 5 days of admission then every recertification. During a joint home visit, on 11/30/23, at 12:45 p.m., with LVN 1 at Patient 2s residence, Patient 2 was observed sitting at chair at the living room with a cane placed next to him. During an interview on 11/30/23, at 1 p.m., Patient 2 was asked if he was informed about the purpose of the hospice care services stated, the hospice service will provide a nurse to visit every week to take his blood pressure and provide him with his prescribed medications. He also stated that he was never told he had six months or less to live. Patient further stated that his friend referred him to the hospice agency. c. A review of Patient 3s admission record indicated a start of care date of 6/25/23 with a terminal diagnoses of chronic ischemic heart disease (damage or disease in the heart's major blood vessels), and hypertensive heart disease without heart failure. A review of Patient 3's POC/IDG form, dated 11/3/23, indicated the frequency of visits of licensed vocational nurse (LVN) to one or two visit per week, social worker (MSW) to conduct initial evaluation within 5 days of admission then every recertification. On 11/30/23, at 3 p.m., during a phone interview with Patient 3, when asked if he knew about hospice service, Patient 3 stated, ";It is a service that I have but exactly what kind of service I dont know." Patient 3 further stated he was not dying, and no doctor or any nurses from the agency told him that he has six months or less to live. During a review of the agencys undated policy and procedure titled, ";Patient Bill of Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. The Patient Bill of Rights/Responsibilities statement defines the right of the patient to be informed in advance of service about the care to be furnished, the organizations scope of services and services under the Medicate Hospice Benefit and any limitations on these services. Findings: a. A review of Patient 1s admission record indicated a start of care (SOC) date of 11/6/2023 with a terminal diagnosis of acute ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 11/17/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one to two visit per week, registered nurse (RN) to conduct initial evaluation within five days of admission then every recertification. During a joint home visit on 11/30/2023, at 11:51 a.m., with LVN 1 at Patient 1s residence, Patient 1 was observed walking steadily at the living room without using an assistive device. During an interview on 11/30/2023, at 12:00 p.m., Patient 1 was asked if she was informed about the purpose of the hospice care services and stated she was never told she had six months or less to live. Patient 1 stated a nurse from the agency would come visit every week to take her blood pressure readings. Patient 1 further stated she never had an attending physician and her friend referred her to the hospice agency. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 11/13/23 with a terminal diagnosis of atherosclerotic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 11/17/23, indicated the frequency of visits of licensed vocational nurse (LVN) to one to two visit per week, to conduct initial evaluation within 5 days of admission then every recertification. During a joint home visit, on 11/30/23, at 12:45 p.m., with LVN 1 at Patient 2s residence, Patient 2 was observed sitting at chair at the living room with a cane placed next to him. During an interview on 11/30/23, at 1 p.m., Patient 2 was asked if he was informed about the purpose of the hospice care services stated, the hospice service will provide a nurse to visit every week to take his blood pressure and provide him with his prescribed medications. He also stated that he was never told he had six months or less to live. Patient further stated that his friend referred him to the hospice agency. c. A review of Patient 3s admission record indicated a start of care date of 6/25/23 with a terminal diagnoses of chronic ischemic heart disease (damage or disease in the heart's major blood vessels), and hypertensive heart disease without heart failure. A review of Patient 3's POC/IDG form, dated 11/3/23, indicated the frequency of visits of licensed vocational nurse (LVN) to one or two visit per week, social worker (MSW) to conduct initial evaluation within 5 days of admission then every recertification. On 11/30/23, at 3 p.m., during a phone interview with Patient 3, when asked if he knew about hospice service, Patient 3 stated, ";It is a service that I have but exactly what kind of service I dont know." Patient 3 further stated he was not dying, and no doctor or any nurses from the agency told him that he has six months or less to live. d. A review of Patient 8s admission record indicated a start of care date of 11/14/2023 with a terminal diagnosis of acute ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 8s IDG/POC form, dated 11/17/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 90 days and as needed for five days for change in health status. On 11/30/2023 at 11 a.m., a joint home visit was conducted with Registered Nurse (RN 2) at Patient 8s home residence. Patient 8 was alert and oriented and well groomed. Patient 8 was asked if able to eat herself and stated that she was able to eat, and able to go to the bathroom and get out of bed by herself with the use of her cane. Patient 8 was also asked if she had a terminal illness or if she was dying stated, she was not dying and enrolled in hospice because she needed more information about her medical situation. During a telephone interview on 11/30/2023, at 4:06 p.m., Patient 8 stated she had a primary physician (PP 1) and was referred to hospice from a ";friend of a friend." During a telephone interview on 11/30/2023, at 4:15 p.m., Primary Physician (PP 1) stated he was the primary care doctor for Patient 8. PP 1 stated that he was not aware Patient 8 was on hospice and did not refer Patient 8 for hospice evaluation. PP1 further stated that Patient 8 does not have a terminal illness and was not eligible for hospice. e. A review of Patient 9s admission record indicated a start of care date of 4/2/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 9s IDG/POC form dated 11/3/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 60 days. During a telephone interview on 11/30/2023 at 3:33 p.m., Family Member 1 (FM 1) stated that she takes care of Patient 9. FM 1 further stated that she was also enrolled in hospice with Patient 9. FM 1 stated that a lady from her church referred both her and Patient 9 to hospice care services. Patient 9 was asked if she had terminal illness and could die within six months, FM 1 stated that both her and Patient 9 did not have a terminal illness and were not going to die within six months. There was no documented evidence FM1, and Patient 9 were informed in advance of the hospice care to be furnished, the organizations scope of services and services under the Medicare Hospice Benefit and any limitations on these services. During a review of the agencys undated policy and procedure titled, ";Patient Bill of Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. The Patient Bill of Rights/Responsibilities statement defines the right of the patient to be informed in advance of service about the care to be furnished, the organizations scope of services and services under the Medicate Hospice Benefit and any limitations on these services. During a review of the agencys undated policy and procedure titled, ";Patient Bill of Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. The Patient Bill of Rights/Responsibilities statement defines the right of the patient to be informed in advance of service about the care to be furnished, the organizations scope of services and services under the Medicate Hospice Benefit and any limitations on these services.

Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of the Patient was met as follows: --- 1. The hospice agency (HA) failed to maintain the current medication profiles for one out of 14 sampled patients (Patient 8). The deficient practice had the potential to put patient at risk for medication errors and adverse drug reactions which can be life threatening. (Refer to L 530). 2. The hospice agency staff failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status, and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness for four out of 14 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 8). (Refer to L532). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Initial and Comprehensive Assessment of Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview, and record review, the hospice staff failed to review all medications patient was taking and update the medication profile with the currently used medications for one out of 14 sampled patients (Patient 8). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions jeopardizing the patient's health status and wellbeing. --- Findings: a. A review of Patient 8s admission record indicated a start of care date of 11/14/2023 with a terminal diagnosis of acute ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 8s Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 11/17/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 90 days and as needed for five days for change in health status. A review of Patient 8s Medication Profile (a written summary of all the medications patient is taking regularly, including over-the-counter and complementary medicines) indicated the following medications: - Acetaminophen (a medication used to treat pain and fever), 500 milligram (mg, a unit of measure), one tablet, oral, every six hours for pain and fever. - Tylenol (acetaminophen, a medication used to treat pain and fever) 500 mg, two tablets, every eight hours for pain and fever greater than 100.4 degrees Fahrenheit (a scale of temperature). - Voltaren (nonsteroidal anti-inflammatory gel used for arthritis [joint inflammation] pain) 10 mg, topical (applied to the skin or body surface), every four to six hours for pain. On 11/30/2023 at 11:00 a.m., a joint home visit was conducted with Registered Nurse (RN 2) at Patient 8s home residence. Patient 8 was observed walking from the doorway to the kitchen table slowly and independently about 18 to 20 steps. Patient 8 was alert and oriented and well groomed. Patient 8s medications were reviewed with RN 2 and the following was observed: - Patient 8 only had Tylenol 325 mg in house instead of Tylenol 500 mg as ordered. - Voltaren 10 mg, topical was not found/available. RN 2 stated that Patient 8 did not have the correct dose of Tylenol and that Patient 8 did not have the Voltaren topical. RN 2 stated it was important to check the medications in each visit to make sure the patient had the correct medications and if there were any changes to the medications to update the medication profile. A review of the hospice agencys undated policy, titled ";Medication Profile", indicated that the medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications.

Based on observation, interview, and record review, the hospice agency failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status, and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness for four out of 14 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 8). This deficient practice resulted in patients admitted for hospice care were not appropriately evaluated by the health care professionals and certified to receive the benefits. --- d. A review of Patient 8s admission record indicated a start of care date of 11/14/2023 with a terminal diagnosis of acute ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 8's Physicians Certification for Hospice Benefit, dated 11/14/2023 to 2/11/2023, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. A review of Patient 8s IDG/POC form, dated 11/17/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 90 days and as needed for five days for change in health status. On 11/30/2023 at 11 a.m., a joint home visit was conducted with Registered Nurse (RN 2) at Patient 8s home residence. Patient 8 was alert and oriented and well groomed. Patient 8 was asked if she was able to eat and stated she was able to eat by herself, and able to go to the bathroom by herself, and get out of bed by herself with the use of her cane. Patient 8 was asked if she had a terminal illness or if she was dying, Patient 8 stated she was not dying and enrolled in hospice because she needed more information about my medical situation. During a telephone interview on 11/30/2023 at 4:06 p.m., Patient 8 stated she had a primary physician (PP 2) and was referred to hospice from a ";friend of a friend", and not by her primary physician. During a telephone interview on 11/30/2023 at 4:15 p.m., Primary Physician (PP 2) stated he was the primary care doctor for Patient 8. PP 2 stated he was not aware Patient 8 was on hospice and did not refer Patient 8 for hospice evaluation. PP 2 stated that he was not contacted by the hospice agency. PP 2 further stated that Patient 8 does not have a terminal illness and was not eligible for hospice. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. Findings: a. A review of Patient 1s admission record indicated a start of care (SOC) date of 11/6/23 with a terminal diagnosis of acute ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 11/6/23 to 2/3/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit, on 11/30/23, at 11:51 a.m., with LVN 1 at Patient 1s residence, Patient 1 was observed walking steadily at the living room without using an assistive device. During an interview on 11/30/23, at 12 p.m., Patient 1 was asked if she was informed about the purpose of the hospice care services and stated, she was never told that she had six months or less to live. Patient 1 stated a nurse from the hospice agency would come visit every week to take her blood pressure readings. Patient 1 further stated that she never had an attending physician and her friend referred her to the hospice agency. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 11/13/23 with a terminal diagnosis of atherosclerotic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 11/13/23 to 2/10/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit, on 11/30/23, at 12:45 p.m., with LVN 1 at Patient 2s residence, Patient 2 was observed sitting at chair at the living room with a cane placed next to him. During an interview on 11/30/23, at 1 p.m., when Patient 2 was asked if he was informed about the purpose of the hospice care services, he stated the hospice service will provide a nurse from the agency to come visit every week to take his blood pressure readings and provides him with his prescribed medications. He also stated that he was never told that he had six months or less to live. He further stated that his friend referred him to the hospice agency. c. A review of Patient 3s admission record indicated a start of care date of 6/25/23 with a terminal diagnosis of chronic ischemic heart disease (damage or disease in the heart's major blood vessels) hypertensive heart disease without heart failure. A review of Patient 3's Physicians Certification for Hospice Benefit, dated 6/25/23 to 9/23/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 11/30/23, at 3 p.m., during a phone interview, Patient 3 was asked what he knew about hospice service and stated, ";It is a service that I have but exactly what kind of service I dont know." Patient 3 further stated he was not dying, and no doctor or any nurses from the hospice agency told him that he has six months or less to live. On 12/1/23, at 11 a.m., during an interview with the DPCS (director of patient care services), she stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital where the patient gets discharged from. On 12/1/23, at 12:30 p.m., during a phone interview with Physician 1, she stated that she was not the attending physician, and did not know who the attending physicians for Patients 1, 2, and 3. Physician 1 stated since Patients 1, 2 and 3 were admitted for hospice service, she now becomes the patient's attending physician, signed the referral attending physician section because no one would sign it. Physician 1 further stated that she determined the patients' eligibility for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated the Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Hospice will admit a patient only on recommendation of the medical director in consultation with or input from the patients attending physician. Findings: a. A review of Patient 1s admission record indicated a start of care (SOC) date of 11/6/23 with a terminal diagnosis of acute ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 11/6/23 to 2/3/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit, on 11/30/23, at 11:51 a.m., with LVN 1 at Patient 1s residence, Patient 1 was observed walking steadily at the living room without using an assistive device. During an interview on 11/30/23, at 12 p.m., Patient 1 was asked if she was informed about the purpose of the hospice care services and stated, she was never told that she had six months or less to live. Patient 1 stated a nurse from the hospice agency would come visit every week to take her blood pressure readings. Patient 1 further stated that she never had an attending physician and her friend referred her to the hospice agency. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 11/13/23 with a terminal diagnosis of atherosclerotic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 11/13/23 to 2/10/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit, on 11/30/23, at 12:45 p.m., with LVN 1 at Patient 2s residence, Patient 2 was observed sitting at chair at the living room with a cane placed next to him. During an interview on 11/30/23, at 1 p.m., when Patient 2 was asked if he was informed about the purpose of the hospice care services, he stated the hospice service will provide a nurse from the agency to come visit every week to take his blood pressure readings and provides him with his prescribed medications. He also stated that he was never told that he had six months or less to live. He further stated that his friend referred him to the hospice agency. c. A review of Patient 3s admission record indicated a start of care date of 6/25/23 with a terminal diagnosis of chronic ischemic heart disease (damage or disease in the heart's major blood vessels) hypertensive heart disease without heart failure. A review of Patient 3's Physicians Certification for Hospice Benefit, dated 6/25/23 to 9/23/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 11/30/23, at 3 p.m., during a phone interview, Patient 3 was asked what he knew about hospice service and stated, ";It is a service that I have but exactly what kind of service I dont know." Patient 3 further stated he was not dying, and no doctor or any nurses from the hospice agency told him that he has six months or less to live. On 12/1/23, at 11 a.m., during an interview with the DPCS (director of patient care services), she stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital where the patient gets discharged from. On 12/1/23, at 12:30 p.m., during a phone interview with Physician 1, she stated that she was not the attending physician, and did not know who the attending physicians for Patients 1, 2, and 3. Physician 1 stated since Patients 1, 2 and 3 were admitted for hospice service, she now becomes the patient's attending physician, signed the referral attending physician section because no one would sign it. Physician 1 further stated that she determined the patients' eligibility for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. d. A review of Patient 8s admission record indicated a start of care date of 11/14/2023 with a terminal diagnosis of acute ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 8's Physicians Certification for Hospice Benefit, dated 11/14/2023 to 2/11/2023, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. A review of Patient 8s IDG/POC form, dated 11/17/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 90 days and as needed for five days for change in health status. On 11/30/2023 at 11 a.m., a joint home visit was conducted with Registered Nurse (RN 2) at Patient 8s home residence. Patient 8 was alert and oriented and well groomed. Patient 8 was asked if she was able to eat and stated she was able to eat by herself, and able to go to the bathroom by herself, and get out of bed by herself with the use of her cane. Patient 8 was asked if she had a terminal illness or if she was dying, Patient 8 stated she was not dying and enrolled in hospice because she needed more information about my medical situation. During a telephone interview on 11/30/2023 at 4:06 p.m., Patient 8 stated she had a primary physician (PP 2) and was referred to hospice from a ";friend of a friend", and not by her primary physician. During a telephone interview on 11/30/2023 at 4:15 p.m., Primary Physician (PP 2) stated he was the primary care doctor for Patient 8. PP 2 stated he was not aware Patient 8 was on hospice and did not refer Patient 8 for hospice evaluation. PP 2 stated that he was not contacted by the hospice agency. PP 2 further stated that Patient 8 does not have a terminal illness and was not eligible for hospice. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated the Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Hospice will admit a patient only on recommendation of the medical director in consultation with or input from the patients attending physician.

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met as follows: --- Findings: 1. The hospice agency failed to ensure the patients' written plan of care was reviewed and revised by the interdisciplinary group no less frequently than every 15 days for seven of 14 sampled patients (Patient 3, Patient 4, Patient 5, Patient 9, Patient 10, Patient 11 and Patient 12). (Refer to L552). 2. The hospice agency failed to ensure home visits were conducted in accordance with the plan of care for six of 14 sampled patients (Patient 3, Patient 4, Patient 5, Patient 9, Patient 10, and Patient 12). (Refer to L555). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services.

Based on interview and record review, the hospice agency failed to ensure the patients' written plans of care (POC) were reviewed and revised by the interdisciplinary group (IDG, a group of health care professionals with various areas of expertise responsible for the holistic care of the hospice beneficiary) no less frequently than every 15 days for seven of 14 sampled patients (Patient 3, Patient 4, Patient 5, Patient 9, Patient 10, Patient 11, and Patient 12). This deficient practice had the potential to result in the hospice patient's progress or decline will not be identified for further intervention and update of the plan of care to meet the patients' hospice needs. --- Findings: a. A review of Patient 3s admission record indicated a start of care date of 6/25/2023 with a terminal diagnosis of chronic ischemic heart disease (damage or disease in the heart's major blood vessels). hypertensive heart disease without heart failure. During a review of Patient 3's clinical record indicated the POC/IDG meetings was conducted on 11/3/2023. There was no documented evidence the POC/IDG meeting was conducted after 11/3/2023. b. A review of Patient 4s admission record indicated a start of care date of 7/27/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. During a review of Patient 4's clinical record indicated the POC/IDG meetings was conducted on 11/3/2023. There was no documented evidence the POC/IDG meeting was conducted after 11/3/2023. c. A review of Patient 5s admission record indicated a start of care date of 7/27/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. During a review of Patient 5's clinical record indicated the POC/IDG meetings was conducted on 11/3/2023. There was no documented evidence the POC/IDG meeting was conducted after 11/3/2023. During an interview on 12/1/2023 at 1:30 p.m., with the Director of Patient Care Services (DPCS), the Office manager (OM), and hospice staff were not able to provide documented evidence the POC/IDG meetings were held every 15 days for Patient 3, Patient 4, and Patient 5. During a review of the hospice agencys policy and procedure titled, ";Interdisciplinary Group Meeting" revised May 2022, indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, death and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. d. A review of Patient 9s admission record indicated a start of care date of 4/2/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 9s IDG/POC form dated 11/3/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 60 days. A review of Patient 9's clinical record indicated the last POC/IDG meeting was conducted on 11/3/2023. There was no documented evidence the POC/IDG meeting was conducted after 11/3/2023. e. A review of Patient 10s admission record indicated a start of care date of 4/9/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (accumulation of plaque in the arteries that supply blood to the heart muscle) without angina pectoris (chest pain). A review of Patient 10s IDG/POC form dated 10/20/2023, indicated the frequency of visits of a skilled nurse (SN) to one to two visits for 60 days and five times as needed in case of health status change. There were no care plans indicated in the IDG/POC. A review of Patient 10s IDG/POC form dated 11/3/2023, indicated the frequency of visits of a skilled nurse (SN) to one to two visits for 60 days and five times as needed in case of health status change. There were no care plans indicated in the IDG/POC. A review of Patient 10s clinical record indicated the last POC/IDG meeting was conducted on 11/3/2023. There was no documented evidence the POC/IDG meeting was conducted after 11/3/2023. f. A review of Patient 11s admission record indicated a start of care date of 4/4/2023 with a terminal diagnosis of heart disease (refers to several types of heart conditions). A review of Patient 11s IDG/POC form, dated 11/3/2023, indicated the frequency of visits of a skilled nurse (SN) to one to two visits for 90 days and five times as needed in case of health status change. A review of Patient 11's clinical record indicated the last POC/IDG meeting was conducted on 11/3/2023. There was no documented evidence that an IDG/POC meeting was conducted after 11/3/2023. g. A review of Patient 12s admission record indicated a start of care date of 3/1/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (accumulation of plaque in the arteries that supply blood to the heart muscle) without angina pectoris (chest pain). A review of Patient 12s IDG/POC form, dated 11/3/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 60 days. A review of Patient 12's clinical record indicated the last POC/IDG meeting was conducted on 11/3/2023. There was no documented evidence that an IDG/POC meeting was conducted after 11/3/2023. During an interview on 12/1/2023 at 1:30 p.m. with the Director of Patient Care Services (DPCS) with the Office manager (OM), the agency staff was not able to provide documented evidence the POC/IDG meetings were held every 15 days for the patients during the above period.

Based on interview and record review, the hospice agency failed to ensure patients' home visits were conducted in accordance with the plan of care (POC) for six of 14 sampled patients (Patient 3, Patient 4, Patient 5, Patient 9, Patient 10, and Patient 12). This failure had the potential to negatively affect the patients' physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. --- Findings: a. A review of Patient 3s admission record indicated a start of care date of 6/25/2023 with a terminal diagnosis of chronic ischemic heart disease (damage or disease in the heart's major blood vessels). hypertensive heart disease without heart failure. A review of Patient 3's POC/IDG form, dated 11/3/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one or two visit per week, social worker (MSW) to conduct initial evaluation within 5 days of admission then every recertification. During a review of Patient 3s history of Nursing Clinical Notes indicated skilled nurse (SN) visited Patient 3 only one time for the month of October 2023. There was no SN visit conducted for the month of November 2023. b. A review of Patient 4s admission record indicated a start of care date of 7/27/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. A review of Patient 4's POC/IDG form, dated 11/3/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one or two visit per week, social worker (MSW) to conduct initial evaluation within 5 days of admission then every recertification. During a review of Patient 4s history of Nursing Clinical Notes indicated SN visited Patient 4 one time for the month of October 2023. There were no SN visits conducted for the month of November 2023. c. A review of Patient 5s admission record indicated a start of care date of 7/27/23 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. A review of Patient 5's POC/IDG form, dated 11/3/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one or two visit per week, social worker (MSW) to conduct initial evaluation within 5 days of admission then every recertification. During a review of Patient 5s history of Nursing Clinical Notes indicated SN visited Patient 5 only one time for the month of October 2023. There were no SN visits conducted for the month of November 2023. On 12/1/23, at 1 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS acknowledged the findings and stated patient care visits should be provided to patients in accordance with the plan of care. During a review of the agency's policy and procedure titled, "The Plan of Care", revised May 2022, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. d. A review of Patient 9s admission record indicated a start of care date of 4/2/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 9s IDG/POC form, dated 11/3/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 60 days. A review of Patient 9s Nursing Clinical Notes indicated there were no SN visits conducted for the month of November 2023. e. A review of Patient 10s admission record indicated a start of care date of 4/9/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (accumulation of plaque in the arteries that supply blood to the heart muscle) without angina pectoris (chest pain). A review of Patient 10s IDG/POC form, dated 11/3/2023, indicated the frequency of visits of a skilled nurse (SN) to one to two visits for 60 days and five times as needed in case of health status change. A review of Patient 10s Nursing Clinical Notes indicated there were no SN visits conducted for the month of November 2023. f. A review of Patient 12s admission record indicated a start of care date of 3/1/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (accumulation of plaque in the arteries that supply blood to the heart muscle) without angina pectoris (chest pain). A review of Patient 12s IDG/POC form, dated 11/3/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 60 days. There was no documented evidence SN visits were conducted as indicated in the POC. During an interview on 12/1/2023 at 1 p.m., the Director of Patient Care Services (DPCS) acknowledged the findings and stated patient care visit should be provided to patients in accordance with the plan of care. During a review of the agency's policy and procedure titled, "The Plan of Care", revised May 2022, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. d. A review of Patient 9s admission record indicated a start of care date of 4/2/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). A review of Patient 9s IDG/POC form, dated 11/3/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 60 days. A review of Patient 9s Nursing Clinical Notes indicated there were no SN visits conducted for the month of November 2023. e. A review of Patient 10s admission record indicated a start of care date of 4/9/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (accumulation of plaque in the arteries that supply blood to the heart muscle) without angina pectoris (chest pain). A review of Patient 10s IDG/POC form, dated 11/3/2023, indicated the frequency of visits of a skilled nurse (SN) to one to two visits for 60 days and five times as needed in case of health status change. A review of Patient 10s Nursing Clinical Notes indicated there were no SN visits conducted for the month of November 2023. f. A review of Patient 12s admission record indicated a start of care date of 3/1/2023 with a terminal diagnosis of atherosclerotic heart disease of native coronary artery (accumulation of plaque in the arteries that supply blood to the heart muscle) without angina pectoris (chest pain). A review of Patient 12s IDG/POC form, dated 11/3/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 60 days. There was no documented evidence SN visits were conducted as indicated in the POC. During an interview on 12/1/2023 at 1 p.m., the Director of Patient Care Services (DPCS) acknowledged the findings and stated patient care visit should be provided to patients in accordance with the plan of care. During a review of the agency's policy and procedure titled, "The Plan of Care", revised May 2022, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. Findings: a. A review of Patient 3s admission record indicated a start of care date of 6/25/2023 with a terminal diagnosis of chronic ischemic heart disease (damage or disease in the heart's major blood vessels). hypertensive heart disease without heart failure. A review of Patient 3's POC/IDG form, dated 11/3/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one or two visit per week, social worker (MSW) to conduct initial evaluation within 5 days of admission then every recertification. During a review of Patient 3s history of Nursing Clinical Notes indicated skilled nurse (SN) visited Patient 3 only one time for the month of October 2023. There was no SN visit conducted for the month of November 2023. b. A review of Patient 4s admission record indicated a start of care date of 7/27/2023 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. A review of Patient 4's POC/IDG form, dated 11/3/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one or two visit per week, social worker (MSW) to conduct initial evaluation within 5 days of admission then every recertification. During a review of Patient 4s history of Nursing Clinical Notes indicated SN visited Patient 4 one time for the month of October 2023. There were no SN visits conducted for the month of November 2023. c. A review of Patient 5s admission record indicated a start of care date of 7/27/23 with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. A review of Patient 5's POC/IDG form, dated 11/3/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one or two visit per week, social worker (MSW) to conduct initial evaluation within 5 days of admission then every recertification. During a review of Patient 5s history of Nursing Clinical Notes indicated SN visited Patient 5 only one time for the month of October 2023. There were no SN visits conducted for the month of November 2023. On 12/1/23, at 1 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS acknowledged the findings and stated patient care visits should be provided to patients in accordance with the plan of care. During a review of the agency's policy and procedure titled, "The Plan of Care", revised May 2022, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Core Services was met as follows: 1. The hospice agency failed to ensure spiritual counselling services was provided to two of 14 sampled patients (Patient 1 and Patient 2). (Refer to L598). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with the Federal Regulations for Core Services to ensure and anticipate reactions of the bereaved, and provision of an ongoing support to the family members after the patient's death.

Based on observation, interview and record review, the hospice agency failed to ensure Spiritual Counseling services was provided for two of 14 sampled patients (Patient 1 and Patient 2). This failure had the potential to result in the patient/family's desires will not be identified and met in a manner consistent with patient and family's belief. --- Findings: a. A review of Patient 1s admission record indicated a start of care (SOC) date of 11/6/2023 with a terminal diagnosis of acute ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form dated 11/17/2023, indicated the frequency of visits of the licensed vocational nurse (LVN) indicated one to two visits per week to conduct initial evaluation within 5 days of admission then every recertification. During a joint home visit on 11/30/2023, at 11:51 a.m., with LVN 1 at Patient 1s residence, Patient 1 was observed walking steadily at the living room without using an assistive device. During an interview on 11/30/2023, at 12 p.m., when Patient 1 was asked if the visiting nurse offered bereavement services and stated, "no", she was not aware about this service but would want a chaplain to come and visit her. During a review of Patient 1's clinical record indicated there was no documented evidence a spiritual assessment was conducted by the hospice agencys Chaplain indicating the service was being offered during the start of care (SOC). b. A review of Patient 2s admission record indicated a start of care (SOC) date of 11/13/2023 with a terminal diagnosis of atherosclerotic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 11/17/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one to two visit per week, to conduct initial evaluation within 5 days of admission then every recertification. During a joint home visit, on 11/30/2023, at 12:45 p.m., with LVN 1 at Patient 2s residence, Patient 2 was observed sitting in a chair at the living room with a cane placed next to him. During an interview on 11/30/2023, at 1 p.m., when Patient 2 was asked if the visiting nurse offered bereavement services and stated "no", but he would like to see a chaplain. During a review of Patient 2's clinical record indicated there was no documented evidence a spiritual assessment was conducted by the hospice agencys Chaplain indicating the service was being offered during the start of care "SOC". During a review of the agency's policy and procedure titled "Spiritual Assessment", revised May 2022, indicated a spiritual assessment will be completed for each patient/family by the Chaplain. The assessment will include, but not be limited to, evaluation of the following: 1. Coping with and adjusting to the patients terminal illness 2. Assessing bereavement needs 3. Religious and/or spiritual reactions to terminal illness

Based on observation, interview, and record review, the Hospice Agency failed to ensure the Condition of Participation for Medical Director was met as evidenced by: --- Findings: 1. The hospice agency failed to ensure the Medical Director and/or physician designee conducted an assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for four out of 17 sampled patients (Patient 1, Patient 2, Patient 3 and Patient 8). (Refer to L667) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory mandated (state law) compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Medical Director and/or physician designee conducted an assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (a hospice physician narrative designed to explain the clinical findings that support a life expectancy of six months or less), to qualify for hospice care and services (health care that focuses on the palliation to ease the symptoms without curing the underlying disease of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) for four of 14 sampled patients (Patient 1, Patient 2, Patient 3, and Patient 8). This deficient practice resulted in the Medical Director certifying these patients without clinical documentation to receive the hospice benefits. --- a. A review of Patient 1s admission record indicated a start of care (SOC) date of 11/6/23 with a terminal diagnosis of acute ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 11/6/23 to 2/3/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit, on 11/30/23, at 11:51 a.m., with LVN 1 at Patient 1s residence, Patient 1 was observed walking steadily at the living room without using an assistive device. During an interview on 11/30/23, at 12 p.m., when Patient 1 was asked if she was informed about the purpose of the hospice care services, she stated she was never told that she had six months or less to live. Patient 1 stated a nurse from the agency would come visit every week to take her blood pressure readings. She further stated that she never had an attending physician and her friend referred her to the hospice agency. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 11/13/23 with a terminal diagnosis of atherosclerotic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 11/13/23 to 2/10/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit, on 11/30/23, at 12:45 p.m., with LVN 1 at Patient 2s residence, Patient 2 was observed sitting at chair at the living room with a cane placed next to him. During an interview on 11/30/23, at 1 p.m., when Patient 2 was asked if he was informed about the purpose of the hospice care services, he stated the hospice service will provide a nurse from the agency to come visit every week to take his blood pressure readings and provides him with his prescribed medications. He also stated that he was never told that he had six months or less to live. He further stated that his friend referred him to the hospice agency. c. A review of Patient 3s admission record indicated a start of care date of 6/25/23 with a terminal diagnosis of chronic ischemic heart disease (damage or disease in the heart's major blood vessels). hypertensive heart disease without heart failure. A review of Patient 3's Physicians Certification for Hospice Benefit, dated 6/25/23 to 9/23/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 11/30/23, at 3 p.m., during a phone interview with Patient 3, when he was asked what he knew about hospice service, Patient 3 stated, ";It is a service that I have but exactly what kind of service I dont know." Patient 3 further stated he was not dying, and no doctor or any nurses from the agency told him that he has six months or less to live. On 12/1/23, at 11 a.m., during an interview with the DPCS (director of patient care services), she stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital where the patient gets discharged from. On 12/1/23, at 12:30 p.m., during a phone interview with Physician 1, she stated that she was not the attending physician, and she does not know who the attending physicians for Patients 1,2, and 3. Physician 1 stated since Patients 1, 2 and 3 were admitted for hospice service, she now becomes the patient's attending physician, signed the referral attending physician section because no one would sign it. Physician 1 further stated that she determined the patients were eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. During a review of the agencys undated policy and procedure titled ";Physician Services-Medical Director", indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care. d. A review of Patient 8s admission record indicated a start of care date of 11/14/2023 with a terminal diagnosis of acute ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 8's Physicians Certification for Hospice Benefit, dated 11/14/2023 to 2/11/2023, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. A review of Patient 8s IDG/POC form, dated 11/17/2023, indicated the frequency of visits of a skilled nurse (SN) to two to three visits per week for 90 days and as needed for five days for change in health status. On 11/30/2023 at 11 a.m., a joint home visit was conducted with Registered Nurse (RN 2) at Patient 8s home residence. Patient 8 was alert and oriented and well groomed. When asked if Patient 8 stated that she was able to eat, and able to go to the bathroom and get out of bed by herself with the use of her cane. When asked if she had a terminal illness or if she was dying, Patient 8 stated she was not dying and enrolled in hospice because she needed more information about my medical situation. During a telephone interview on 11/30/2023 at 4:06 p.m., Patient 8 stated she had a primary physician (PP 2) and was referred to hospice from a ";friend of a friend." During a telephone interview on 11/30/2023 at 4:15 p.m., Primary Physician (PP 2) stated he was the primary care doctor for Patient 8. PP 2 stated that he was not aware Patient 8 was on hospice and did not refer Patient 8 for hospice evaluation. PP 2 stated that he was not contacted by the hospice agency. PP 2 further stated that Patient 8 does not have a terminal illness and is not eligible for hospice. a. A review of Patient 1s admission record indicated a start of care (SOC) date of 11/6/2023 with a terminal diagnosis of acute ischemic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 11/6/2023 to 2/3/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit, on 11/30/2023, at 11:51 a.m., with licensed vocational nurse (LVN 1) at Patient 1s residence, Patient 1 was observed walking steadily at the living room without using an assistive device. During an interview on 11/30/2023, at 12 p.m., when Patient 1 was asked if she was informed about the purpose of the hospice care services, she stated she was never told that she had six months or less to live. Patient 1 stated a nurse from the agency would come visit every week to take her blood pressure readings. She further stated that she never had an attending physician and her friend referred her to the hospice agency. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 11/13/2023 with a terminal diagnosis of atherosclerotic heart disease (damage or disease in the heart's major blood vessels). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 11/13/2023 to 2/10/2023, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit, on 11/30/2023, at 12:45 p.m., with LVN 1 at Patient 2s residence, Patient 2 was observed sitting at chair at the living room with a cane placed next to him. During an interview on 11/30/2023, at 1 p.m., when Patient 2 was asked if he was informed about the purpose of the hospice care services, he stated the hospice service will provide a nurse from the agency to come visit every week to take his blood pressure readings and provides him with his prescribed medications. He also stated that he was never told that he had six months or less to live. He further stated that his friend referred him to the hospice agency. c. A review of Patient 3s admission record indicated a start of care date of 6/25/2023 with a terminal diagnosis of chronic ischemic heart disease (damage or disease in the heart's major blood vessels). hypertensive heart disease without heart failure. A review of Patient 3's Physicians Certification for Hospice Benefit, dated 6/25/2023 to 9/23/2023, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 11/30/2023, at 3 p.m., during a phone interview with Patient 3, when he was asked what he knew about hospice service, Patient 3 stated, ";It is a service that I have but exactly what kind of service I dont know." Patient 3 further stated he was not dying, and no doctor or any nurses from the agency told him that he has six months or less to live. On 12/1/2023, at 11 a.m., during an interview with the DPCS (director of patient care services), she stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital where the patient gets discharged from. On 12/1/2023, at 12:30 p.m., during a phone interview with Physician 1, she stated that she was not the attending physician, and she does not know who the attending physicians for Patients 1,2, and 3. Physician 1 stated since Patients 1, 2 and 3 were admitted for hospice service, she now becomes the patient's attending physician, signed the referral attending physician section because no one would sign it. Physician 1 further stated that she determined the patients were eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. During a review of the agencys undated policy and procedure titled ";Physician Services-Medical Director", indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to ensure the RN conduct and document in writing a patient-specific comprehensive assessment that identified the patient's need for hospice care and services as noted in organization policy. For example: it was noted throughout all medical records reviewed that the RN comprehensive assessment lacked documentation of Nature and condition causing admission (including the presence or lack of objective data and subjective complaints) and Patient's past and present medical and psychosocial history including pertinent diagnosis and any co-morbid conditions as called for in policy 2-030.1 sections C and K. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 2 of 5 patient records reviewed, the organization failed to ensure that the update of the comprehensive assessment was accomplished by the hospice interdisciplinary group considering the changes that took place since the initial assessment no less frequently than every 15 days. For example: upon review of RR#4 and RR#5 it was noted that there was no documented IDG meeting to discuss changes that had taken place after the patient was discharged from hospice services. This observation was reviewed with the Administrator/DPCS.

Observed in HR File Review. In 1 of 1 HR files reviewed, for hospice aide, the organization failed to ensure that the initial competency validation evaluation included all areas that were included on the organization's Initial Competency Assessment Skills Checklist as accepted per policy. For example: Upon review of the hospice aide HR file it was noted that the aide's initial competency included observation of the required elements, however there were many other skills left blank that were on the checklist yet not addressed. These unassessed areas included toileting/elimination, urinary catheter care, hoyer lift, and concepts of death and dying, among others. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 1 of 1 patient records reviewed, that was receiving hospice aide services, the organization failed to ensure that the registered nurse provided clear and complete written patient care instruction to the aide. For example: upon review of RR#4 it was noted that all tasks assigned to the aide on the written hospice aide assignment lacked a specified frequency. This observation was reviewed with the Administrator/DPCS.

Observed in HR File Review. In 6 of 9 HR files reviewed, the organization failed to ensure that the initial competency validation evaluation included all areas that were included on the organization's Initial Competency Assessment Skills Checklist as accepted per policy. For example: upon review of HR#2 (RN Supervisor/Designee) the registered nurse initial competency was initiated and signed and included observation for some of the skills listed on the competency checklist, however many skills were not addressed and left blank by the clinician providing the competency evaluation. Skills not addressed included: concepts of death and dying, review of systems and symptom management, among many others. The competencies for the LVN, Chaplain, Administrator/DPCS, Volunteer, and Volunteer Coordinator have similar findings of competency checklist initiated, signed, and some skills observed, yet many other skills not addressed and left blank. These observations were reviewed with the Administrator/DPCS.

Observed in Record Review. In 3 of 5 patient records reviewed, the organization failed to ensure that the physician written certification of terminal illness documentation that the patient’s life expectancy is six months or less if the illness runs its normal course contained all of the required elements. For example: Upon review of the CTI for HV#1 the physicians narrative lacked all of the required elements. The narrative read patient 80 years old female admitted to hospice routine level of care with admitting terminal diagnosis of malignant neoplasm of right breast. Has gen weakness and KPS = 50% as end of life stage. The summary lacked current subjective and objective medical findings and other required elements to demonstrate the patient's life expectancy of 6 months or less if the disease takes a normal course. This observation was reviewed with the Administrator/DPCS.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization failed to ensure that the clinical record contained all information necessary to fully reflect the patient's care, treatment, and services. For example: upon review of HV#1 it was noted that the record lacked the patient's medical history leading to the patient's admission to hospice care. Similar findings of minimal to no history and physical can be noted throughout all records reviewed. This observation was reviewed with the Administrator/DPCS.