Every finding on record at Avn Hospice Care

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Patients rights was met as follows: The HA failed to ensure patients were informed and that the agency explained all the Medicare (federal health insurance for people 65 or older) and non-Medicare coverage for hospice service that the patient could receive, and failed to ensure that the patient understand the information provided, for six of six patients (Patient 1, 2, 3, 4, 5 and 6). This deficient practice resulted in the patients being misinformed about hospice care and services covered benefits. (Refer to L 518). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Patient's Rights to protect and promote the rights, of the patient in the hospice agency. --- .

Based on an interview and record review, the hospice agency failed to inform and explain all the Medicare (federal health insurance for people 65 or older) and non Medicare coverage for hospice services that patient's could receive, and ensure the patient understood the information provided, for six of six patients (Patient 1, 2, 3, 4, 5, and 6). This deficient practice resulted in the patients being misinformed about hospice care and services covered benefits. --- d. A review of Patient 4s Patient Information Sheet indicated a Start of Care (SOC) date of 9/19/2022 with a primary diagnosis of acute (sudden onset, sharp rise, and short course) ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). e. A review of Patient 5s Patient Information Sheet indicated a Start of Care (SOC) date of 7/29/2022 with a primary diagnosis of heart disease (heart condition that affects the major blood vessels that supply the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). f. A review of Patient 6s Patient Information Sheet indicated a Start of Care (SOC) date of 10/20/2022 with a primary diagnosis of hypertensive heart disease without heart failure and secondary diagnosis of acute ischemic heart disease. During an interview on 5/2/2023 at 12:25 pm, when the Director of Patient Care Services was asked to provide the patient consent forms to the Surveyor Team, the DPCS stated she did not know where the patient files were kept in the agency. During a telephone interview on 5/4/2023 at 1:05 pm, the Family Member (FM 1) stated she lived with Patient 6 and that Patient 6 was still working and healthy. FM 1 stated that there was no doctor or nurse that came to her house to tell Patient 6 about hospice but did remember that last year, someone came to give Ensure (supplemental drink), shampoo and toothpaste and took down Patient 6 and her husbands names and information. FM 1 stated that Patient 6 was not terminally ill and never signed any election of benefits for hospice services. During an interview on 5/4/2023 at 2:18 pm, the Director of Patient Care Services designee (DPCSD) stated the consents and election of benefits should be signed at the beginning of the start of care and that the nurse was responsible for getting the signatures. The DPCSD stated it was the DPCS and the intake coordinators responsibility to check the patients chart and ensure the documentation is completed. During an interview with the Administrator designee (ADMD) on 5/4/2023 at 2:33 pm, the ADMD stated the all the patient records that were requested were not retrievable and that if it was not documented, it was not done. A review of the HAs (undated) policy, Hospice Election Statement indicated the patient and family/caregiver, or his/her legal representative, will be asked to sign the hospice election statement which acknowledges the following: A. A full understanding of the palliative, rather than the curative nature of hospice care a. A review of Patient 1s Patient Information Sheet indicated a Start of Care (SOC) date of 08/02/2022 with a primary diagnosis of diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen). A review of Patient 1s clinical records indicated that there was no patient consents found. During a telephone interview on 5/3/2023 at 6:28 pm, the Family Member (FM 1) stated that she lives with Patient 1 and that patient is healthy and has not received any hospice services. FM 1 stated that there was no doctor or nurse who came to see Patient 1 and that the only person that came was an agent who gave them ensure, shampoo and toothpaste. FM 1 further stated that Patient 1 never signed any documents regarding hospice services. b. A review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) date of 08/05/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) A review of Patient 2s clinical records indicated that there was no patient consents found. c. A review of Patient 3s Patient Information Sheet indicated a Start of Care (SOC) date of 09/23/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) A review of Patient 3s clinical records indicated that there was no patient consents found.

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Initial and Comprehensive Assessment of the Patient was met as evidenced by: 1. The Hospice Agency (HA) failed to conduct an accurate comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and identified the patients needs for hospice care and services related to eligibility and management of the terminal illness, for six of six sampled patients, (Patients 1, 2, 3, 4, 5, and 6). This deficient practice resulted in the provision of hospice services for patients who were not clinically eligible to receive hospice care and services. (Refer to L524). 2. The hospice agency (HA) failed to review all medications and update the medication profiles with the currently used medications two of six sampled patients, (Patients 4 and 6). The deficient practice resulted in patients not receiving medications as ordered by the physician and had a potential to result in adverse side effects if the medications were not administered timely. (Refer to L 530). 3. The hospice agency (HA) failed to develop and implement a bereavement assessment and plan for one of six sampled patients (Patient 4). The deficient practice had the potential to place the family at risk of not receiving support and services after the patient's death. (Refer to L531). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Patient's Rights to protect and promote the rights, of the patient in the hospice agency. --- .

Based on interview, and record review, the hospice agency failed to conduct an accurate comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) that reflected the patients current health status and identified the patients needs for hospice care and services related to eligibility and management of the terminal illness, for six of six sampled patients, (Patients 1, 2, 3, 4, 5, and 6). This deficient practice resulted in the provision of hospice services to patients were not clinically eligible to receive hospice care and services. --- d. A review of Patient 4s Patient Information Sheet indicated a Start of Care (SOC) date of 9/19/2022 with a primary diagnosis of acute (sudden onset, sharp rise, and short course) ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). A review of Patient 4s Initial Comprehensive Assessment, dated 9/19/2022, indicated that Patient 4 had a primary diagnosis of Acute ischemic heart disease and secondary diagnosis of hypertensive heart disease without heart failure and chest pain. The assessment indicated that Patient 4 had a New York Heart Association classification (NYHA, a simple way of classifying the extent of heart failure) of Class IV [severe symptoms such as fatigue, palpitations (tremors or shivers) chest pain, dyspnea (difficulty breathing), or syncope (fainting) with features of heart failure with minimal physical activity and even at rest] level. The assessment indicated that Patient 4 had clear lung sounds, normal respirations and no cough or cardiac related pain. The assessment did not indicate that Patient 4 had tremors or fainting episodes. The assessment was not signed by a Registered Nurse (RN). A review of Patient 4s undated form titled, "LCD Hospice Eligibility Determination" (LCD, Local Coverage Determination, an assessment to determine a patients eligibility for hospice services) for Heart Disease indicated Patient 4 met the criteria for New York Heart Association classification as Class IV [severe symptoms such as fatigue, palpitations (tremors or shivers) chest pain, dyspnea (difficulty breathing), or syncope (fainting) with features of heart failure with minimal physical activity and even at rest] level and had a history of unexplained syncope (fainting) and brain embolism (clot) of cardiac (heart) origin. The HA was unable to provide patient records to indicate that Patient 4 had a NYHA Classification IV, unexplained syncope or a brain embolism. e. A review of Patient 5s Patient Information Sheet indicated a Start of Care (SOC) date of 7/29/2022 with a primary diagnosis of heart disease (heart condition that affects the major blood vessels that supply the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). A review of Patient 5s Initial Comprehensive Assessment dated 7/29/2022, did not indicate vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and that the Body System (Head to Toe) Assessment which included neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, nutrition and skin assessment was not performed and was left blank. The assessment indicated that Patient 5 had a New York Heart Association classification (NYHA, a simple way of classifying the extent of heart failure) of Class IV [severe symptoms such as fatigue, palpitations (tremors or shivers) chest pain, dyspnea (difficulty breathing), or syncope (fainting) with features of heart failure with minimal physical activity and even at rest] level. The Comprehensive Assessment was not signed by an RN. A review of Patient 5s undated form titled, "LCD Hospice Eligibility Determination" (LCD, Local Coverage Determination, an assessment to determine a patients eligibility for hospice services) for Heart Disease indicated Patient 5 met the criteria for New York Heart Association classification as Class IV [severe symptoms such as fatigue, palpitations (tremors or shivers) chest pain, dyspnea (difficulty breathing), or syncope (fainting) with features of heart failure with minimal physical activity and even at rest] level and had a brain embolism (clot) of cardiac (heart) origin. The HA was unable to provide patient records to indicate that Patient 5 had a NYHA Classification IV or a brain embolism. f. A review of Patient 6s Patient Information Sheet indicated a Start of Care (SOC) date of 10/20/2022 with a primary diagnosis of hypertensive heart disease without heart failure and secondary diagnosis of acute ischemic heart disease. A review of Patient 6s Initial Comprehensive Assessment dated 10/20/2022, did not indicate vital signs (clinical measurements, specifically pulse rate, temperature, respiration rate, and blood pressure, that indicate the state of a patient's essential body functions) and that the Body System (Head to Toe) Assessment which included neurological, cardiovascular, respiratory, gastrointestinal, genitourinary, nutrition and skin assessment was not performed and was left blank. The assessment did not indicate did not indicate the nature and Condition terminal Illness/ LCD Eligibility and was left blank. The Comprehensive Assessment was not signed by an RN. A review of Patient 6s undated form titled, "LCD Hospice Eligibility Determination" (LCD, Local Coverage Determination, an assessment to determine a patients eligibility for hospice services) indicated that it was not filled out and that the ";Patient does not qualify per LCD Guidelines." During an interview on 5/4/2023 at 2:08 pm, the Director of Patient Care Services designee (DCPSD) stated that the patients comprehensive assessment should be completed withing 48 hours and the nurse performing the assessment should sign it. During an interview with the Administrator designee (ADMD) on 5/4/2023 at 2:33 pm, ADMD stated that the patient records were not retrievable and if it was not provided, it was not done. The ADMD stated that HA was unable to use their wireless internet services to access the HAs HospiceMD program (an accessible and secure web-based application used to manage, access and update patient electronic health records) account to retrieve patient records. A review of the Hospice Agencys (undated) policy, Admission Criteria and Process, indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCD). The policy further indicated that the HA would admit a patient only on recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any. A review of the Hospice Agencys (undated) policy, Initial Assessment indicated that an initial assessment will be performed by a registered nurse within 48 hours after election of hospice care unless otherwise specified by the physician, patient, or representative to be completed in less than 48 hours. The initial assessment will be filed in the patients clinical records. The policy indicated that if the comprehensive assessment is completed during the admission visit, the initial assessment will be included as part of the comprehensive assessment. A review of the Hospice Agencys (undated) policy, Comprehensive Assessment, indicated that during the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant: ... G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patients terminal illness. a. A review of Patient 1s Patient Information Sheet indicated a Start of Care (SOC) date of 08/02/2022 with a primary diagnosis of diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen). A review of Patient 1s Comprehensive Nursing Assessment dated 08/03/2022 indicated that it was signed by RN 1 on 03/18/2023. A review of Patient 1s undated LCD Hospice Eligibility Determination (Local Coverage Determination - an assessment to determine a patients eligibility for hospice services) indicated that the sections was incomplete and that patient does not qualify per LCD guidelines. b. A review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) date of 08/05/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) A review of Patient 2s Comprehensive Nursing Assessment dated 08/05/2022 indicated that the sections regarding vitals and measurements, mobility, DME device, nature and condition of terminal illness, and body system where not completed. Further review of the Comprehensive Nursing Assessment dated 08/05/2022 indicated that it was not signed by a Registered Nurse (RN). c. A review of Patient 3s Patient Information Sheet indicated a Start of Care (SOC) date of 09/23/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) A review of Patient 3s Comprehensive Nursing Assessment dated 09/23/2022 indicated that it was not signed by a Registered Nurse (RN).

Based on interview and record review, the Hospice Agency (HA) failed to review all medications and update the medication profiles with the currently used medications for two of six sampled patients (Patients 4 and 6). The deficient practice had the potential to result in patients to not receive medications as ordered by the physician and had a potential to result in adverse side effects if the medications were not administered timely. --- a. A review of Patient 4s Patient Information Sheet indicated a Start of Care (SOC) date of 9/19/2022 with a primary diagnosis of acute (sudden onset, sharp rise, and short course) ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). A review of Patient 4s Medication Profile indicated the following: - Carvedilol, 3.125 mg tablet, one tab by mouth, frequency ";1" and indication ";DAILY" - Diltiazem Hydrocloride, 30 mg one tab by mouth, frequency ";1" and indication ";DAILY" - Rosuvastatin Calcium, 5 mg, one tab by mouth, frequency ";1" and indication ";DAILY" During an interview with the DPCSD on 5/4/23 at 2:25 pm, Patient 6s Medication Profile was reviewed. The DPCSD stated the frequency and indication on the Medication Profile was incorrect and the medications should be checked every visit and the nurse should have updated and corrected the frequency and indication of the medication. b. A review of Patient 6s Patient Information Sheet indicated a Start of Care (SOC) date of 10/20/22 with a primary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and secondary diagnosis of acute ischemic heart disease. During a concurrent interview and record review with the DPCSD on 5/4/23 at 2:21 p.m., Patient 6s Medication Profile was reviewed. The DPCSD stated the Medication Profile was blank and that the nurse should have performed a medication reconciliation during the patients initial assessment. The DPCSD stated the nurse should check the medication bottles for the name of the patient, the name of the medication, the prescription, dosage, frequency and the indication of the medication. A review of the Hospice Agencys undated policy titled ";Medication Profile" indicated patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.

Based on interview and record review, the hospice agency failed to ensure a bereavement assessment and bereavement plan was developed and implemented to discuss and document the family/caregiver's needs after the patient's' death for one of six sampled patients (Patient 4), according to the agency's policy. This deficient practice placed the family at a potential risk for not receiving support and preparation for what to expect after the patient's' death. --- A review of Patient 4s Patient Information Sheet indicated a Start of Care (SOC) date of 9/19/22 with a primary diagnosis of acute (sudden onset, sharp rise, and short course) ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). A review of Patient 4s Discharge Summary dated 1/15/23 indicated the reason for discharge was death and end of care (EOC) was 1/15/23. The Discharge Summary indicated ";Staff received a call from patient caregiver and reported the patient passed away." There was no documented summary related to diagnosis, health history, symptom pain management, extent to which goals were and were not met and a summary of post-discharge continuity of care orders. The summary did not include when the physician was notified, the patients time of death and vital signs at time of death or if the nurse performed post-mortem care. The discharge summary was not signed. Patient 4s initial bereavement and post bereavement assessment (a tool used to assess the needs of the patient and family, focused on the social, spiritual, and cultural factors that may impact their ability to cope with the patients death) was requested, but the Hospice Agency was not able to provide the documents. During an interview and record review with the Director of Patient Care Services designee (DPCSD) on 5/4/23 at 2:10 pm, Patient 4s Discharge Summary was reviewed. The DPCSD stated the discharge summary did not indicate the time of death, the vital signs at the time of death, or that post-mortem care or medication reconciliation and disposal was performed. The DPCSD stated the nurse should have documented this information in the patients chart. The DPCSD further stated she was hired on 1/17/23 and did not know that Patient 4 had died. When asked if she was aware that one patient out of 67 discharged patients from the hospice agency was discharged due to death within the last year, the DPCSD stated she was not notified. The DPCSD stated that no card or letters were sent to the patients family. A review of the hospice agencies untitled policy titled, "Bereavement Assessment," indicated on admission, the social worker or registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator. The policy indicated that after death occurs, the hospice social worker or Bereavement Coordinator will develop a plan for intervention, based on the findings of the bereavement follow-up assessment and input from interdisciplinary group members. The policy indicated that within two weeks after the death of a patient, a sympathy card will be sent to the bereaved and after three weeks a bereavement letter will be sent to the bereaved giving support and outlining the hospice bereavement services. The policy indicated all bereavement documentation will be submitted for filing in the patient's permanent clinical record.

Based on an 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: 1. The hospice agency failed to have every member of the interdisciplinary group (IDG, a group of healthcare professionals responsible for the holistic care of the hospice beneficiary.) participate in the interdisciplinary group meeting for two of nine sample patients (Patient 1 and 3). (Refer to L543) 2. The hospice agency failed to ensure its interdisciplinary group (IDG) reviewed and revised the patient's care plans in consultation with the physician, social worker and chaplain and document in the HospiceMD program (an accessible and secure web-based application used to manage, access and update patient electronic health records) for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6). (Refer to L552) 3. The hospice agency failed to assist a family/caregiver when the HA was notified of a patients death for one of six sampled patients (Patient 4). (Refer to L554) 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 (HA) failed to designate an interdisciplinary group (IDG), in consultation with the patients physician, to prepare the written plan of care (POC) within two days of Start of Care (SOC) for six of six sampled patients (Patient 1, 2, 3, 4, 5, and 6). There was no physician consulted regarding the development of the plan of care and there was no social worker, and Chaplain had participated in preparing the patients' POC. This deficient practice had the potential to prevent the patients from reaching their care planning goals. --- d. A review of Patient 4s Patient Information Sheet indicated a Start of Care (SOC) date of 9/19/2022 with a primary diagnosis of acute (sudden onset, sharp rise, and short course) ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). A review of Patient 4s Plan of Care (POC)/Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Review, dated 12/14/2022, 12/28/2022, and 1/11/2023 indicated for a POC for Chest Pain with interventions that included to assess/monitor cardiac status every visit, assess and monitor effectiveness of medications and to instruct patient/patient caregiver/family on non-pharmacological intervention such as breathing exercises, therapeutic touch and music therapy. The POC/IDG indicated that the POC for Chest Pain was opened on the SOC 9/19/2022 and signed by Maintenance Worker/Volunteer (MWV 1) with ";ADMN (Administrator)" after his name. The POC/IDG was not signed by the Medical Director, Registered Nurse, Social Worker or Chaplain. During an interview on 5/3/2023 at 4:10 pm, when the Owner was asked who the MWV 1 was, the Owner stated that MWV 1 was an all-around handyman, plumber, volunteer but not a clinician. When the Owner was asked why MWV 1s name was on Patient 4s clinical record, the Owner stated I dont know if he has access to HospiceMD. e. A review of Patient 5s Patient Information Sheet indicated a Start of Care (SOC) date of 7/29/2022 with a primary diagnosis of heart disease (heart condition that affects the major blood vessels that supply the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). A review of Patient 5s Initial Comprehensive Assessment dated 7/29/2022, indicated in the narrative that a plan of care was formulated with the IDT (interdisciplinary team). A review of Patient 5s Plan of Care (POC)/ Interdisciplinary Group (IDG) Review dated 7/29/2022 indicated routine level of care, Registered Nurse Visit once per week with two visits as needed. There was no IDT discussion was performed by nursing, spiritual, psychosocial and physician and the sections were blank. There was no Plan of Care (problem/intervention/goals/status), and the section was left blank. The POC/IDG was not signed by the Medical Director, Registered Nurse, Social Worker or Chaplain. The HA was unable to provide the Plan of Care developed by the Interdisciplinary Group when Patient 5 was admitted at SOC. f. A review of Patient 6s Patient Information Sheet indicated a Start of Care (SOC) date of 10/20/2022 with a primary diagnosis of hypertensive heart disease without heart failure and secondary diagnosis of acute ischemic heart disease. During an interview on 5/3/2023 at 2:02 pm, the Administrator designee (ADMD) stated that there should be a care plan developed when the hospice patient is admitted and that there should be an IDT meeting performed every 14 days and should be signed in HospiceMD. During an interview with the Administrator designee (ADMD) on 5/4/2023 at 2:33 pm, ADMD stated that the patient records were not retrievable and if it was not provided, it was not done. The ADMD stated that HA was unable to use their wireless internet services to access the HAs HospiceMD program (an accessible and secure web-based application used to manage, access and update patient electronic health records) account to retrieve patient records. The HA was unable to provide the Plan of Care developed by the Interdisciplinary Group when Patient 6 was admitted at SOC. A review of the Hospice Agencys (undated) policy, The Plan of Care, indicated that 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. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days. a. A review of Patient 1s Patient Information Sheet indicated a Start of Care (SOC) date of 08/02/2022 with a primary diagnosis of diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen). A review of Patient 1s Physicians Certification for Hospice Benefits dated 08/03/2022, indicated that RN 1 was the one who signed and not Medical Director (MD 2). Further review Patient 1s Physicians Certification for Hospice Benefits dated 08/03/2022, indicated that the plan of care was formulated with the Interdisciplinary Team (IDT). A review of Patient 1s Plan of Care (POC)/ Interdisciplinary Group (IDG) Review dated 12/23/2022, 01/06/2023 and 01/20/2023 indicated routine level of care. Further review of the POC/IDG Review dated 12/23/2022, 01/06/2023 and 01/20/2023 indicated that the sections level of care and frequency of visits was blank. The POC/IDG was not signed by the Medical Director, Registered Nurse, Social Worker or Chaplain. The HA was unable to provide records for Patient 1s initial POC/IDG. b. A review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) date of 08/05/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) A review of Patient 2s Physicians Certification for Hospice Benefits dated 08/05/2022, indicated that Owner was the one who signed and not Medical Director (MD 2). Further review Patient s Physicians Certification for Hospice Benefits dated 08/05/2022, indicated that the plan of care was formulated with the Interdisciplinary Team (IDT). A review of Patient 2s clinical records indicated that there was no Plan of Care (POC)/ Interdisciplinary Group (IDG) Review provided. c. A review of Patient 3s Patient Information Sheet indicated a Start of Care (SOC) date of 09/23/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) A review of Patient 3s Physicians Certification for Hospice Benefits dated 09/23/2022, indicated that RN 1 was the one who signed and not Medical Director (MD 2). Further review Patient 1s Physicians Certification for Hospice Benefits dated 09/23/2022, indicated that the plan of care was formulated with the Interdisciplinary Team (IDT). A review of Patient 3s Plan of Care (POC)/ Interdisciplinary Group (IDG) Review dated 11/06/2022, 11/20/2022 and 12/04/2022 indicated that the sections level of care and frequency of visits was blank. The POC/IDG was not signed by the Medical Director, Registered Nurse, Social Worker or Chaplain. The HA was unable to provide records for Patient 3s initial POC/IDG.

Based on interview and record review, the hospice agency (HA) failed to ensure its interdisciplinary group (IDG) reviewed and revised the patient's care plans in consultation with the physician, social worker and chaplain and document in the HospiceMD program (an accessible and secure web-based application used to manage, access and update patient electronic health records) for six of six sampled patients (Patients 1, 2, 3, 4, 5, and 6). This deficient practice resulted in the IDG did not review the patient's care plans which had the potential to result in failure to identify changes in the patient's progress and not updating the plan of care. --- d. A review of Patient 4s Patient Information Sheet indicated a Start of Care (SOC) date of 9/19/2022 with a primary diagnosis of acute (sudden onset, sharp rise, and short course) ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). A review of Patient 4s Plan of Care (POC)/Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Review, dated 12/14/2022, 12/28/2022, and 1/11/2023 indicated for a POC for Chest Pain with interventions that included to assess/monitor cardiac status every visit, assess and monitor effectiveness of medications and to instruct patient/patient caregiver/family on non-pharmacological intervention such as breathing exercises, therapeutic touch and music therapy. The level of care and frequency of visit were left blank. The POC/IDG was not signed by the Medical Director, Registered Nurse, Social Worker or Chaplain. The HA was unable to provide records for Patient 4s POC/IDG dated 9/19/2022. e. A review of Patient 5s Patient Information Sheet indicated a Start of Care (SOC) date of 7/29/2022 with a primary diagnosis of heart disease (heart condition that affects the major blood vessels that supply the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). A review of Patient 5s Plan of Care (POC)/ Interdisciplinary Group (IDG) Review dated 7/29/2022 indicated routine level of care, Registered Nurse Visit once per week with two visits as needed. There was no IDT discussion was performed by nursing, spiritual, psychosocial and physician and the entries were blank. There was no Plan of Care (problem/intervention/goals/status) and the section was left blank. The POC/IDG was not signed by the Medical Director, Registered Nurse, Social Worker or Chaplain. The HA was unable to provide the Patient 5s last three POC/IDG Reviews for the week of 9/9/2022, 9/23/2023 or 10/07/2022. f. A review of Patient 6s Patient Information Sheet indicated a Start of Care (SOC) date of 10/20/2022 with a primary diagnosis of hypertensive heart disease without heart failure and secondary diagnosis of acute ischemic heart disease. During a concurrent interview and record review with the Director of Patient Care Services designee (DPCSD) on 5/4/2023 at 2:31 pm, Patient 6s clinical records were reviewed. There was no POC/IDG provided. When asked why there was no IDT/POC provided, the DPCSD stated I do not know what happened, I was not here at the time. During an interview with the Administrator designee (ADMD) on 5/4/2023 at 2:33 pm, ADMD stated that the records were not retrievable and if it was not provided, it was not done. The ADMD stated that HA was unable to use their wireless internet services to access the HAs HospiceMD program (an accessible and secure web-based application used to manage, access and update patient electronic health records) account to retrieve patient records. A review of the HAs (undated) policy titled ";Interdisciplinary Group Coordination of Care," indicated that written evidence of care coordination will be found in the plan of care and/or interdisciplinary group meeting forms in the patient's clinical record and will involve the hospice patient's attending physician. A review of the HAs (undated) policy titled ";Interdisciplinary Group Meeting," indicated that members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor. A review of the Hospice Agencys (undated) policy, The Plan of Care, indicated that 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. The plan of care will meet the documentation requirements of the physician-directed medical orders and the care planning process. The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every 15 days. a. A review of Patient 1s Patient Information Sheet indicated a Start of Care (SOC) date of 08/02/2022 with a primary diagnosis of diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen). A review of Patient 1s Plan of Care (POC)/ Interdisciplinary Group (IDG) Review dated 12/23/2022, 01/06/2023 and 01/20/2023 indicated routine level of care. Further review of the POC/IDG Review dated 12/23/2022, 01/06/2023 and 01/20/2023 indicated that the sections level of care and frequency of visits was blank. The POC/IDG was not signed by the Medical Director, Registered Nurse, Social Worker or Chaplain. b. A review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) date of 08/05/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) A review of Patient 2s clinical records indicated that there was no Plan of Care (POC)/ Interdisciplinary Group (IDG) Review provided. c. A review of Patient 3s Patient Information Sheet indicated a Start of Care (SOC) date of 09/23/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) A review of Patient 3s Plan of Care (POC)/ Interdisciplinary Group (IDG) Review dated 11/06/2022, 11/20/2022 and 12/04/2022 indicated that the sections level of care and frequency of visits was blank. The POC/IDG was not signed by the Medical Director, Registered Nurse, Social Worker or Chaplain.

Based on interview and record review, the Hospice Agency (HA) failed to assist the family/caregiver, when the HA was notified of a patients death for one of six sampled patients (Patient 4). This deficient practice placed the family/caregiver at risk for not receiving psychosocial support or assistance after the patient's death. --- A review of Patient 4s Patient Information Sheet indicated a Start of Care (SOC) date of 9/19/22 with a primary diagnosis of acute (sudden onset, sharp rise, and short course) ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). A review of Registered Nurse (RN) visit note dated 1/15/23 indicated Patient 4's vital signs were as follows: temperature 97.8, pulse 69 beats per minute, respirations-19, breaths per minute, blood pressure 135/80, and oxygen saturation of 96%. The visit note indicated Patient 4 was lying in bed, awake with increased confusion, periods of agitation and calming measures and redirection provided. The visit note indicated Patient 4 had no signs of shortness of breath or respiratory distress during the visit. The visit note was signed by RN 1. A review of Patient 4s Discharge Summary dated 1/15/23 indicated the reason for discharge was death. The end of care (EOC) was on 1/15/2023. The Discharge Summary indicated ";Staff received a call from patient caregiver and reported the patient had passed away." There was no documented summary related to Patient 4's diagnosis, health history, symptom pain management, extent to which goals were and were not met and a summary of post-discharge continuity of care orders. The summary did not include when the physician was notified, the patients time of death or the vital signs at time of death or if the nurse performed post-mortem care. The discharge summary was not signed. During an interview on 5/2/23 at 3:40 pm, the Owner stated RN 1 resigned on 1/13/23 and went to the Philippines and never came back. The Owner stated she was not able to provide a copy of RN 1s resignation letter. During an interview on 5/3/23 at 1:09 p.m., the Director of Patient Care Services (DPCS) stated RN 1 resigned on 1/13/23 and the HA did not know who visited Patient 4 on 1/15/23. During an interview and record review with the Director of Patient Care Services designee (DPCSD) on 5/4/23 at 2:10 p.m., Patient 4s Discharge Summary was reviewed. The DPCSD stated the discharge summary did not indicate the time of death, the vital signs at the time of death, or that post-mortem care or medication reconciliation and disposal was performed. The DPCSD stated that the nurse should have documented in the patients chart. The DPCSD further stated she was hired on 1/17/23 and did not know Patient 4 had died. When asked if she was aware one patient out of 67 discharged patients from the hospice agency was discharged due to death within the last year, the DPCSD stated she was not notified. The DPCSD stated that no card or letters were sent to the patients family. During an interview on 5/4/2023 at 2:11 pm, the DPCSD stated the patients vital signs and time of death should be documented in the discharge summary. The DPCSD stated the nurse should document that postmortem care and medication disposal was performed and the mortuary was notified. The DPCSD stated the social worker and chaplain should be called to provide emotional care to the family. A review of the HAs undated policy, "Death at Home," indicated the nurse will notify the attending physician of the patients death. It will be the attending physician's responsibility to pronounce death (depending on state regulations). This will be done explicitly when the physician signs the death certificate. The physician will routinely accept hospice's description or report of the absence of vital signs when assuming this responsibility. If the nurse is not at the patient's home when the death occurs, this will be communicated to the physician. The policy indicated that all deaths at home will be reported to the medical coroner or appropriate legal entity per state regulations. The coroner's office generally authorizes release of the body from its jurisdiction after the following information is provided by the mortuary, nurse, and/or attending physician: A. Name and address of the deceased B. Deceased date of birth C. Approximate time of death D. Name and telephone number of physician who will sign death certificate. E. Date of last physician contact (if unknown or more than 20 days, encourage the physician to notify coroner) F. Medical diagnoses. G. Next of kin (power of attorney) who have been notified. H. Any unusual circumstances regarding death, e.g., suspicion of foul play. I. Name of mortuary

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Organization and Administration of Services was met as follows: 1. The hospice agency failed to ensure the administrator was knowledgeable regarding hospice regulations and the agency's daily operation. (Refer to L651). 2. The hospice agency failed to ensure the Administrator, Administrator designee, Director of Patient Care Services, and Director of Patient Care Services designee were knowledgeable and oriented in their specific roles. (Refer L662). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Organization and Administration of Services to protect and promote the rights of the patient in the hospice agency. --- .

Based on observation, interview and record review, the hospice agency failed to ensure the Administrator was knowledgeable regarding hospice regulations and agency's daily operation. The deficient practice resulted in the Administrator's lack of knowledge regarding hospice regulations, and the agency not being fully operational. --- On 5/3/2023 requested a second surveyor access to the agencys electronic charting system HospiceMD so that record reviews can be conducted. During a telephone interview with the Administrator (ADM) on 05/03/2023, at 11:07 a.m, he stated the agency currently has no access to HopiceMD and was unaware when access would be available. The Administrator stated that the reason why there was no access to HospiceMD was because they overcharged the agency and the invoices are being reviewed and until issue is resolve there is no access to HospiceMD. During a concurrent observation and interview with the administrator on 5/3/23 at 12:22 p.m., 12:36 p.m. and 12:42 p.m., he stated he was also the administrator for Hospice Agency (HA 2), Hospice Agency (HA 3) and Hospice Agency (HA 4). The administrator was observed looking for the hospice regulations online and was unable to locate the correct regulations. The Administrator stated he did not know the guidelines or regulations that govern hospice agencies. On 5/3/23 at 12:57 p.m., the administrator called the HospiceMD representative but the Administrator was unable to obtain any information because he does not have access to the account and the only person that has access is the owner. The HospiceMD representative stated they sent an email in the morning regarding the issue. On 5/3/23 at 1:03 p.m., the Owner was on a call with HospiceMD and was informed by the HospiceMD representative that the agencys account had been suspended and placed on hold due to non-payment. During an interview with the Owner and Administrator (ADM) on 5/3/23 at 4:35 p.m., they stated the Administrator does not have access to the agency email. The Owner stated the only people who have access are the owner, CEO Volunteer 1 and CEO Volunteer 2. On 5/3/23 at 11:05 p.m., the Department received an email from the Administrator indicating he was notifying the Owner he would be on a leave of absence effective 5/4/23 to 6/4/23. The email further indicated any work-related questions or queries may be directed to his email. During an interview with the Administrator Designee (ADMD) on 5/4/23 at 12:45 p.m., he stated the free trial for the internet expired and that is why the internet is no longer working. A review of an email provided by the Owner, indicated that HospiceMD had emailed her on 10/18/2022 at 4:03 p.m., informing her that the card had declined and to confirm with her bank so that payment can be processed. A review of the agencys undated job description titled ";Executive Director/Administrator" indicated that the Executive Director/Administrator is responsible for the overall direction of the day to day operations of the hospice services. The job description further indicated they are responsible for establishing standards of care to comply with federal and state regulations and guidelines.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Administrator, Administrator designee, Director of Patient Care Services, and the Director of Patient Care Services designee were oriented to their specific roles and responsibility. This deficient practice had the potential to result in poor and inadequate hospice services and care provided to the patients. --- On 5/2/23, during a review of the Administrator's (ADM) employee file, there was no orientation provided or performed. On 5/2/23, the ADM designee's employee file was reviewed. There was no documented evidence that an orientation was performed or provided. On 5/2/23, the Director of Patient Care Services (DPCS) employee file was reviewed. There was no documented evidence an orientation was provided or performed. On 5/2/23, the DPCS designee employee file was reviewed. There was no documented evidence an orientation was provided or performed. During an interview on 5/2/23, the DPCS stated the ADMD and the DPCSD were responsible for maintaining the employee file. A review of the HA undated policy, "Personnel Record Contents," indicated the content of the personnel files for regular full or part-time personnel will include: New Hire DocumentsA. Evidence of pre-employment interviewB. Individual job qualificationsC. Employment applicationD. ResumeE. References (2)F. Offer letterG. Diploma (copy) or educational transcriptsH. Specialty practice certification certificatesI. Verification of education/trainingJ. Statement of formal training for non-professionalsK. Orientation checklist (completed)L. Initial competency assessments

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: 1. The hospice agency failed to ensure that the medical director had a completed employee file and contract. (Refer to L666) 2. The hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications of six of six sampled patients, (Patients 1, 2, 3, 4, 5, and 6) to support diagnosis of the patients terminal illnesses and to qualify for hospice (healthcare that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. (Refer to L 667). 3. The hospice agency failed to ensure the medical director and/or physician designee conducted accurate recertification of terminal illness for continued hospice care and services for one of six sample patients (Patients 4) by failing to ensure Patient 4's recertification had the physician's documentation of clinical information (including current history and physician's, laboratory, and imaging data biopsy results, etc.), that the Medical Director or attending physician completed a certification narrative and has the agency's physician's signature to support diagnoses of terminal illnesses in order to determine continuous hospice care and services. (Refer to L 668) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services. --- .

Based on interview and record review, the hospice agency failed to ensure the medical director had a completed employee file and contract. This deficient practice resulted in the agency not having a completed employee file and contract which had the potential to place the patients at risk for not having a medical director to oversee their care. --- On 5/4/23, the employee file for the Medical Director (MD 2) was requested. During an interview with the Owner on 5/4/23, at 1:47 p.m., she stated that there was no employee file for MD 2. A review of the agencys undated policy and procedure titled ";Personnel Record Contents," indicated personnel records will be retained in a manner that allows each to be easily retrievable and in keeping with applicable local, state, and federal law time frames.

Based on interview, and record review, the hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial certifications of six of six sampled patients, (Patients 1, 2, 3, 4, 5, and 6) to support the diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. These deficient practices resulted in the hospice medical director and/or the hospice attending physicians certifying the patients for hospice care, without documentation of clinical evidence to support the terminal illness diagnoses and could result in a lack of and inappropriate care provided to the patients. --- d. A review of Patient 4s Patient Information Sheet indicated a Start of Care (SOC) date of 9/19/2022 with a primary diagnosis of acute (sudden onset, sharp rise, and short course) ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). A review of Patient 4s Certificate of Terminal Illness (CTI #1): Statement for the First 90-day period effective 9/19/2022 to 12/17/2022 indicated that Patient 4s primary diagnosis was Acute Ischemic heart disease and secondary diagnosis of hypertensive heart disease without heart failure and angina pectoris. The CTI #1 indicated Medical Director (MD2) as the Medical Director with the signature and date signed by Registered Nurse (RN 1). e. A review of Patient 5s Patient Information Sheet indicated a Start of Care (SOC) date of 7/29/2022 with a primary diagnosis of heart disease (heart condition that affects the major blood vessels that supply the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). A review of Patient 5s CTI #1: Statement for the First 90-day period dated 7/29/2022 to 10/26/2022 indicated that Patient 5s primary diagnosis was heart disease and secondary diagnosis of hypertensive heart disease without heart failure and angina pectoris. The CTI indicated that the certification was based on team assessment. The CTI indicated in the Certifying Physician summary that ";Per IDT (interdisciplinary team, members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) discussion and recommendation, the patient remains appropriate for hospice services at this time." The CTI #1 indicated Medical Director (MD2) as the Medical Director with the signature and date left blank for Medical Director Attestation and Certification. A review of Patient 5s Plan of Care (POC)/ Interdisciplinary Group (IDG) Review dated 7/29/2022 indicated routine level of care, Registered Nurse Visit once per week with two visits as needed. There was no IDT discussion was performed by nursing, spiritual, psychosocial and physician and the entries were blank. There was no Plan of Care (problem/intervention/goals/status) and the section was left blank. The POC/IDG was not signed by the Medical Director, Registered Nurse, Social Worker or Chaplain. f. A review of Patient 6s Patient Information Sheet indicated a Start of Care (SOC) date of 10/20/2022 with a primary diagnosis of hypertensive heart disease without heart failure and secondary diagnosis of acute ischemic heart disease. A review of Patient 6s CTI #1: Statement for the First 90-day period dated 10/20/2022 to 10/27/2022 indicated that Patient 6s primary diagnosis was heart disease and secondary diagnosis of hypertensive heart disease without heart failure and angina pectoris. The CTI #2 did not indicate what the certification was based on (Medical history, records and patient status, team assessment or face to face encounter) and the section was left blank. There was no functional status, RN Prognosis summary or certifying physician summary and the sections were left blank. The CTI #1 indicated Medical Director (MD2) as the Medical Director with the signature and date left blank for Medical Director Attestation and Certification. During an interview on 5/8/2023 at 10:34 am, Medical Director (MD 2) stated she did not work for the HA and did not attend IDT meetings for the HAs patients. MD 2 stated she found out that an HA employee had put MD 2s name on the HAs patients records. When asked if MD 2 signed Patient 4s CTI #1, she did not know who the patient was and was not aware of any other patients in the HA that had her name on their records. MD 2 stated she did not apply to be the HAs Medical Director and did not have access to HospiceMD (an accessible and secure web-based application used to manage, access and update patient electronic health records) to see the HA's patient records. A review of the hospice agencys (undated) policy titled, Certification of Terminal Illness indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy, if the disease runs its normal course, by the attending physician and the hospice Medical Director. The policy indicated the time of admission to hospice, the hospice Medical Director or the patients attending physician will complete a certification narrative that reflects the patient's individual circumstances based on his/her review of the patients medical record or, if applicable, examination of the patient. The hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms. a. A review of Patient 1s Patient Information Sheet indicated a Start of Care (SOC) date of 08/02/2022 with a primary diagnosis of diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen). A review of Patient 1s Physicians Certification for Hospice Benefits for the period of 08/03/2022 to 10/31/2022, indicated that RN 1 was the one who signed and not Medical Director (MD 2). Further review Patient 1s Physicians Certification for Hospice Benefits dated 08/03/2022, indicated that the plan of care was formulated with the Interdisciplinary Team (IDT). A review of Patient 1s Plan of Care (POC)/ Interdisciplinary Group (IDG) Review dated 12/23/2022, 01/06/2023 and 01/20/2023 indicated routine level of care. Further review of the POC/IDG Review dated 12/23/2022, 01/06/2023 and 01/20/2023 indicated that the sections level of care and frequency of visits was blank. The POC/IDG was not signed by the Medical Director, Registered Nurse, b. A review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) date of 08/05/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) A review of Patient 2s Physicians Certification for Hospice Benefits for the period of 08/05/2022 to 11/02/2022, indicated that Owner was the one who signed and not Medical Director (MD 2). Further review Patient s Physicians Certification for Hospice Benefits dated 08/05/2022, indicated that the plan of care was formulated with the Interdisciplinary Team (IDT). A review of Patient 2s clinical records indicated that there was no Plan of Care (POC)/ Interdisciplinary Group (IDG) Review provided. c. A review of Patient 3s Patient Information Sheet indicated a Start of Care (SOC) date of 09/23/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) A review of Patient 3s Physicians Certification for Hospice Benefits for the period of 09/23/2022 to 12/21/2022indicated that RN 1 was the one who signed and not Medical Director (MD 2). Further review Patient 1s Physicians Certification for Hospice Benefits dated 09/23/2022, indicated that the plan of care was formulated with the Interdisciplinary Team (IDT). A review of Patient 3s Plan of Care (POC)/ Interdisciplinary Group (IDG) Review dated 11/06/2022, 11/20/2022 and 12/04/2022 indicated that the sections level of care and frequency of visits was blank. The POC/IDG was not signed by the Medical Director, Registered Nurse, Social Worker or Chaplain.

Based on interview, and record review, the hospice agency failed to ensure the medical director and/or physician designee conducted accurate recertification of terminal illness for continued hospice care and services, for one of six sampled patients (Patients 4) by failing to: ensure that Patients 4s recertification had the physician's documentation of clinical information (including current history and physician's, laboratory and imaging data biopsy results, etc.), a physicians narrative of the patient and had the agency's physician's signature to support diagnoses of terminal illnesses in order to determine continuous hospice care and services. This deficient practice resulted in the hospice medical director and/or the hospice attending physician recertifying the patients to continue the hospice services, with inaccurate terminal diagnoses and lack of documentation of clinical evidence to support the diagnoses, that could result in lack and inappropriate care and services. --- d. A review of Patient 4s Patient Information Sheet indicated a Start of Care (SOC) date of 9/19/22 with a primary diagnosis of acute (sudden onset, sharp rise, and short course) ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). A review of Patient 4s Certificate of Terminal illness (CTI #2): Re-Certification Statement for Second 90-day period for 12/18/22 to 3/17/23 indicated Patient 4s primary diagnosis was acute ischemic heart disease and secondary diagnosis of hypertensive heart disease without heart failure and angina pectoris. The CTI #2 did not indicate what the certification was based on (Medical history, records and patient status, team assessment or face to face encounter and the section was left blank. The CTI #2 indicated NYHA level IV but Patient 4s diagnosis did not include heart failure. The Physician narrative for the certifying physician summary was left blank. The CTI #1 indicated Medical Director (MD2) as the Medical Director with the signature and date left blank for the Medical Director Attestation and Certification. During an interview on 5/8/23 at 10:34 a.m., Medical Director (MD 2) stated she did not work for the HA and did not attend IDT meetings for the HAs patients. MD 2 stated she found out that an HA employee had put MD 2s name on the HAs patients records. When asked if MD 2 signed Patient 4s CTI #1, she did not know who the patient was and was not aware of any other patients in the HA that had her name on their records. MD 2 stated she did not apply to be the HAs Medical Director and did not have access to HospiceMD (an accessible and secure web-based application used to manage, access and update patient electronic health records) to see the HA's patient records. A review of the hospice agencys undated policy titled, Certification of Terminal Illness, indicated a subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patients medical record or, if applicable, examination of the patient.

Based on interview and record review, the hospice agency (HA) failed to maintain patient clinical records in accordance with federal guidelines as evidenced by the following: 1. The Hospice Agency (HA) failed to ensure the documentation and entries in the electronic medical record (EMR) for two of six sampled patients (Patient 1 and Patient 4) were accurate and authentic. (Refer to L679). 2. The Hospice Agency (HA) failed to retain the Patient Clinical Records (route sheets, hospice consents, history and physical, and etc.) for six of six sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6) for six years after discharge in accordance with its policy and procedure. (Refer to L681). 3. The Hospice Agency (HA) failed to complete discharge summaries for six of six sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). (Refer to L684). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for clinical records to ensure highest quality of patient care were provided to the patients certified to receive hospice services. --- .

Based on record review and interview, the Hospice Agency (HA) failed to ensure the documentation and entries in the electronic medical record (EMR) for two of six sampled patients (Patient 1 and Patient 4) were accurate and authentic. This deficient practice resulted in the failure to document accurately and ensure the authenticity of the patients clinical records. --- A review of Patient 4s Patient Information Sheet indicated a Start of Care (SOC) date of 9/19/2022 and end of care date of 1/15/2023 with a primary diagnosis of acute (sudden onset, sharp rise, and short course) ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). A review of Patient 4s Certificate of Terminal Illness (CTI #1), dated 9/19/2022, indicated that Patient 4s primary diagnosis was Acute Ischemic heart disease. The CTI #1 indicated Medical Director (MD2) signed for Medical Director Attestation and Certification. A review of Patient 4s Plan of Care (POC)/Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Review, dated 12/14/2022, 12/28/2022, and 1/11/2023 indicated for a POC for Chest Pain with interventions that included to assess/monitor cardiac status every visit, assess and monitor effectiveness of medications and to instruct patient/patient caregiver/family on non-pharmacological intervention such as breathing exercises, therapeutic touch and music therapy. The POC/IDG indicated that the POC for Chest Pain was opened on the SOC 9/19/2022 and signed by Maintenance Worker/Volunteer (MWV 1) with ";ADMN (Administrator)" after his name. A review of Registered Nurse (RN) visit note dated 1/15/2023 indicated the patient vital signs as Temperature 97.8, pulse 69, respirations 19, blood pressure 135/80, and oxygen saturation as 96%. The visit note indicated that Patient 4 was lying in bed, awake with increased confusion, period of agitation and provided by calm measure and redirection. The visit note indicated that Patient 4 had no signs of shortness of breath or respiratory distress during the visit. The visit note was signed by Registered Nurse (RN 1). A review of Patient 4s Discharge Summary dated 1/15/2023 indicated the reason for discharge was death and end of care (EOC) was 1/15/2023. The Discharge Summary indicated that ";Staff received a call from patient caregiver and reported the patient passed away." There was no documented summary related to diagnosis, health history, symptom paint management, extent to which goals were and were not met and a summary of post-discharge continuity of care orders. The summary did not include when the physician was notified, the patients time of death and vital signs at time of death or if the nurse performed post-mortem care. The discharge summary was not signed. During an interview on 5/2/2023 at 3:40 pm, the Owner stated that RN 1 resigned on 1/13/2023 and went to the Philippines and never came back. The Owner stated that she was not able to provide a copy of RN 1s resignation letter. A review of RN 1s HospiceMD Activity History indicated that RN 1s last logged into HospiceMD was 4/21/2023. During an interview on 5/3/2023 at 1:09 pm, the Director of Patient Care Services (DPCS) stated that RN 1 resigned on 1/13/2023 and that the HA did not know who visited Patient 4 on 1/15/2023. During an interview on 5/3/2023 at 4:10 pm, when the Owner was asked who the MWV 1 was, the Owner stated that MWV 1 was an all-around handyman, plumber, volunteer but not a clinician. When the Owner was asked why MWV 1s name was on Patient 4s clinical record, the Owner stated I dont know if he has access to HospiceMD. A review of Patient 4s Certificate of Terminal Illness (CTI #1), dated 9/19/2022, indicated that Patient 4s primary diagnosis was Acute Ischemic heart disease. The CTI #1 indicated Medical Director (MD2) signed for Medical Director Attestation and Certification. During an interview on 5/8/2023 at 10:34 am, Medical Director (MD 2) stated she did not work for the HA and did not attend IDT meetings for the HAs patients. MD 2 stated she was not aware who the patients were in the HA. MD 2 stated she found out that an HA employee had put MD 2 name on the HAs patients records. MD 2 stated she did not apply to be the HAs Medical Director and did not have access to HospiceMD to see the HA patient records. During an interview with the Administrator designee (ADMD) on 5/4/2023 at 2:33 pm, ADMD stated that the records were not retrievable and if it was not provided, it was not done. The ADMD stated that HA was unable to use their wireless internet services to access the HAs HospiceMD program (an accessible and secure web-based application used to manage, access and update patient electronic health records) account to retrieve patient records. During an interview on 5/3/2023 at 1:11 pm, the ADMD stated that when a HA staff resigns, the ADM can deactivate their HospiceMD access. The ADMD stated that he had no idea if RN 1s Hospice MD access was deactivated. During an interview on 5/3/2023 at 4:10 pm, when the Owner was asked who the MWV 1 was, the Owner stated that MWV 1 was an all-around handyman, plumber, volunteer but not a clinician. When the Owner was asked why MWV 1s name was on Patient 4s clinical record, the Owner stated I dont know if he has access to HospiceMD. A review of the HAs (undated) policy, ";Entries into the Clinical Record," indicated that hospice personnel providing direct patient care and supervisory functions have authority to make entries in the clinical record. The policy indicated that a clinical record will be initiated and maintained for each patient receiving care or services, according to organization policies found in this manual, and will include at a minimum: A. Client notice of patient rights, consent, authorization, and elections forms, as applicable B. Pertinent medical history C. Physician (or other authorized licensed independent practitioner) orders and evidence of physician oversight activities D. Initial plan of care, updated plans of care, initial, comprehensive and updated comprehensive assessments and clinical notes E. Dates, times, and types of interventions, assessments, and coordination of care F. Patient response to care and services analyzed and documented as measurable goals G. Current patient status and progress toward goals H. Patient and family education I. Patient language and communicate needs J. Reasons for interruptions in the provision of care and services 2. Entries into the clinical record will be made only by organization personnel and/or by contract personnel who have a written agreement with the organization. a. A review of Patient 1s Patient Information Sheet indicated a Start of Care (SOC) date of 08/03/2022 with a primary diagnosis of diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen). A review of Patient 1s Visit Note RN, indicated that on 01/24/2023 Registered Nurse 1 (RN 1) conducted an in person visit to Patient 1s home. The Visit Note RN indicated that RN 1 conducted an assessment on Patient 1 and that note was electronically signed by RN 1 on 01/24/2023 A review of Patient 1s Visit Note RN, indicated that on 02/01/2023 Registered Nurse 1 (RN 1) conducted an in person visit to Patient 1s home. The Visit Note RN indicated that RN 1 conducted an assessment on Patient 1 and that note was electronically signed by RN 1 on 02/01/2023 During an interview with Registered Nurse (RN 1) on 05/02/2023, at 10:50 a.m., she stated that resigned from the agency on 01/13/2023 or 01/14/2023 but cant recall exact date. RN 1 stated that the last time she visited patients in Delano, California was last year 2022. RN 1 stated that she did not document on HospiceMD and that she is 70 years old and does not know how to use a computer. RN 1 stated that she gives her paper documentation to someone in the office and the person puts it on HospiceMD. RN 1 further stated that she does not sign or do anything on HospiceMD.

Based on interview and record review, the hospice agency (HA) failed to retain the Patient Clinical Records (route sheets, hospice consents, history and physical, and etc.) for six of six sampled patients (Patients 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6) for six years after discharge in accordance with its policy and procedure. This deficient practice resulted in the failure to safeguard, retain, and retrieve the patients clinical records. --- a. A review of Patient 1s Patient Information Sheet indicated a Start of Care (SOC) date of 08/02/2022 with a primary diagnosis of diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen). b. A review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) date of 08/05/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) c. A review of Patient 3s Patient Information Sheet indicated a Start of Care (SOC) date of 09/23/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) d. A review of Patient 4s Patient Information Sheet indicated a Start of Care (SOC) date of 9/19/2022 with a primary diagnosis of acute (sudden onset, sharp rise, and short course) ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). e. A review of Patient 5s Patient Information Sheet indicated a Start of Care (SOC) date of 7/29/2022 with a primary diagnosis of heart disease (heart condition that affects the major blood vessels that supply the heart muscle) and secondary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen) and angina pectoris (chest pain). f. A review of Patient 6s Patient Information Sheet indicated a Start of Care (SOC) date of 10/20/2022 with a primary diagnosis of hypertensive heart disease without heart failure and secondary diagnosis of acute ischemic heart disease. During an interview on 5/3/2023 at 11:49 am, when asked to provide the patient consents and nurse visit route sheets, the ADMD stated the HA did not know where the patient where the records were kept. The ADMD stated it was important to keep these documents because it was an official record of the patient. The ADMD further stated that the consent was an agreement between the HA and the patient, where the patient acknowledges that they agree that their hospice benefits can be used and that the patient is notified of their rights and hospice responsibilities. During an interview with the Administrator designee (ADMD) on 5/4/2023 at 2:33 pm, ADMD stated that the patient records were not retrievable and if it was not provided, it was not done. The ADMD stated that HA was unable to use their wireless internet services to access the HAs HospiceMD program (an accessible and secure web-based application used to manage, access and update patient electronic health records) account to retrieve patient records. A review of the HA's policy titled "Record Retention", (undated), indicated that clinical records will be retained for seven (7) years. When a patient is discharged/expires, paper records will be stored on the premises for two (2) years. After 2 years, the records will be properly labeled, boxed and stored off site in a secure storage facility. a. A review of Patient 1s Patient Information Sheet indicated a Start of Care (SOC) date of 08/03/2022 with a primary diagnosis of diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen).

Based on interview and record review, the hospice agency (HA) failed to complete discharge summaries for six of six sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). This deficient practice resulted in the status of the patients health condition at discharge to be unknown. --- Findings: c. A review of Patient 4s Patient Information Sheet indicated a Start of Care (SOC) date of 9/19/2022 with a primary diagnosis of acute (sudden onset, sharp rise, and short course) ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle). A review of Patient 4s clinical record indicated that there was no discharge plan performed. A review of Patient 4s Discharge Summary dated 1/15/2023 indicated the reason for discharge was death and end of care (EOC) was 1/15/2023. The Discharge Summary indicated that ";Staff received a call from patient caregiver and reported the patient passed away." There was no documented nursing narrative about Patient 4s summary related to diagnosis, health history, symptom paint management, extent to which goals were and were not met and a summary of post-discharge continuity of care orders. The summary did not include when the physician was notified, the patients time of death and vital signs at time of death or if the nurse performed post-mortem care. A review of Patient 4s clinical record indicated that there were no Interdisciplinary Group (IDG) notes related to the discharge nor any nursing visit notes pertaining to Patient 4s death. During an interview and record review with the Director of Patient Care Services designee (DPCSD) on 5/4/2023 at 2:10 pm, Patient 4s Discharge Summary was reviewed. The DPCSD stated that the discharge summary did not indicate the time of death, the vital signs at the time of death, that post-mortem care or medication reconciliation and disposal was performed. The DPCSD stated that the nurse should have documented it in the patients chart. d. A review of Patient 5s Patient Information Sheet indicated a Start of Care (SOC) date of 7/29/2022 with a primary diagnosis of heart disease (a disease that affects the heart or blood vessels). A review of Patient 5 clinical record indicated that there was no discharge plan performed. A review of Patient 5s Discharge Summary indicated the reason for discharge was declined further services and an EOC date of 10/2/2022. The nurses narrative note was blank. A review of Patient 5s clinical record indicated that there were no IDG notes related to the discharge. e. A review of Patient 6s Patient Information Sheet indicated a Start of Care (SOC) date of 10/20/2022 with a primary diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen). A review of Patient 6 clinical record indicated that there was no discharge plan performed. A review of Patient 6s Discharge Summary indicated the reason for discharge was declined further services and an EOC date of 10/17/2022. The nurses narrative note was blank. A review of Patient 6s clinical record indicated that there were no IDG notes related to the discharge. During an interview on 5/4/2023 at 2:11 pm, the DPCSD stated that the patients vital signs and time of death should be documented in the discharge summary. The DPCSD stated that the nurse should document that postmortem care and medication disposal was performed and that the mortuary was notified. The DPCSD stated that the social worker and chaplain should be called to provide emotional care to the family. A review of the HAs (undated) policy titled ";Discharge From Hospice Program, indicated the hospice interdisciplinary group will develop a discharge plan that will include any necessary family counseling, patient education or other services needed prior to discharge. When a patient is discharged, relevant information will include: · Reason for discharge · Physical and psychosocial status at time of transfer or discharge, including specific medical, psychosocial, or other problems requiring interventions or follow-up. · Summary of the care provided and progress toward achieving goals, including both positive and adverse patient responses to treatment or services. · Instruction and referrals provided to the patient. · The date of discharge, which is the date of the last visit made. a. A review of Patient 1s Patient Information Sheet indicated a Start of Care (SOC) date of 08/02/2022 with a primary diagnosis of diagnosis of hypertensive heart disease (heart conditions caused by high blood pressure) with heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the bodys needs for blood and oxygen). A review of Patient 1s clinical record indicated that there was no discharge plan performed. b. A review of Patient 2s Patient Information Sheet indicated a Start of Care (SOC) date of 08/05/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) A review of Patient 2s Discharge Summary indicated the reason for discharge was declined further services and an EOC date of 10/5/2022. The nurses narrative note was blank. A review of Patient 2s clinical record indicated that there was no discharge plan performed. c. A review of Patient 3s Patient Information Sheet indicated a Start of Care (SOC) date of 09/23/2022 with a primary diagnosis of diagnosis of chronic ischemic heart disease (a heart condition caused by narrowed heart (coronary) arteries that supply blood to the heart muscle) A review of Patient 3s clinical record indicated that there was no discharge plan performed.

Based on interview and record review, the hospice agency (HA) failed to maintain patient clinical records in accordance with federal guidelines as evidenced by the following: The Administrator, Administrator Designee, and Director of Patient Care Services did not meet the qualifications in the HA job description. (Refer to L784). The HA failed to perform criminal background checks for the Medical Director, Director of Patient Care Services Designee, the Administrator, and the Social Worker. (Refer to L795). The cumulative effect of this systemic practice resulted in the failure of the hospice to ensure the highest quality of care is provided to the patients certified to receive hospice services. --- .

Based on interview and record review, the Hospice Agency failed to ensure the Administrator, Administrator Designee, and Director of Patient Care Services (DPCS) met the qualifications in the HA job description. This deficient practice had the potential to result in the risk for the HA to employ unqualified staff. --- During an interview on 5/3/2023 at 12:46 p.m., the DPCS stated she did not meet the Director of Patient Care Services (DPCS) job description requirements. The DPCS stated she had her Registered Nurse (RN) license for less than one year. During an interview on 5/3/2023 at 12:30 p.m., the Administrator (ADM) stated he was an Administrator for four of the Owners hospice agencies. During an interview on 5/3/2023 at 12:38 p.m., the ADM stated the DPCS was a registered nurse so she was qualified to be a Director of Patient Care Services for the hospice agency. During an interview on 5/3/2023 at 12:42 p.m., the ADM stated he did not know the guidelines or regulations that govern hospice services. During an interview on 5/4/2023 at 3:41 p.m., the ADMD stated he was a Licensed Vocational Nurse (LVN) since 2021 and had been working for a hospice agency doing intakes. A review of the HAs job description for the Clinical Director/Director of Patient Care Services indicated that the Clinical Director/Director of Patient Care Services shall qualify for the position by fulfilling the requirements under one of the following categories, unless the individual has been previously approved for such employment by a program flexibility issued for the individual's current position at the hospice agency prior to April 1, 1995 or: A. Three years of management experience within the last five years in a hospice or related health care organization, at least one year of which was a supervisory or administrative capacity. B. A registered nurse with four years' experience within the last five years in a hospice agency, primary care clinic or health facility, at least one year of which was in a supervisory or administrative capacity. A review of the HAs job description for the Executive Director/Administrator indicated position qualification of training and experience in health service administration and at least one (1) year of supervisory experience in health-related programs. The job description indicated that the ADM understands hospice care and the services provided to patient and family/caregiver through an interdisciplinary group and had intimate knowledge of Medicare Hospice Certification. A review of the HAs job description for the Administrator Designee (ADMD) indicated position qualifications of training and experience in health service administration and at least one (1) year of supervisor experience in health-related programs. The job description indicated the ADM understands hospice care and the services provided to patient and family/caregiver through an interdisciplinary group and had intimate knowledge of Medicare Hospice Certification.

Based on interview and record review, the hospice agency (HA) failed to perform criminal background checks for the Medical Director, Director of Patient Services Designee, the Administrator, and the Social Worker. This deficient practice had the potential to allow individuals with a criminal background to work for the HA and result in potential harm the HAs patients. --- During a review of the HA's Administrator's (ADM) employee file, the file was incomplete. The ADM employee file did not have a completed job application, a criminal background check, completed orientation checklist, or a signed job description. The ADM employee file did not have a physical exam (within six months of hire), education verification, or any experience in hospice or training as an HA Administrator. The ADM employment application dated 3/1/2023, indicated the ADM employment history was left blank. During a concurrent interview and record review of employee records with the Director of Patient Care Services Designee (DPCSD) on 1/6/2023 at 10:57 a.m., the employee records for the Social Worker (SW), Medical Director (MD 1), and Director of Patient Care Services Designee (DPCSD) were reviewed. The DPCSD stated the background checks for the SW, MD 1, and DPCSD were not in the employee files and that it should have been there. The DPCSD stated it was important to make sure the HA checked whether the employee does not have a felony or any illegal background areas before they begin working with patients. During an interview on 5/2/2023 at 3:58 p.m., the Director of Patient Care Services (DPCS) stated the Administrator Designee (ADMD) and the DPCSD were responsible for maintaining the employee files. The DPCS stated the ADMD and the DPCS needs to make sure the training and license expirations dates were updated. During an interview on 5/2/2023 at 4 p.m., the Owner stated she and the ADM were responsible for performing the background checks. A review of the facility's undated policy "Personnel Record Contents", indicated the content of the personnel files for regular full or part-time personnel will include: New Hire Documents A. Evidence of pre-employment interview. B. Individual job qualifications. C. Employment application. D. Resume E. References (2) F. Offer letter G. Diploma (copy) or educational transcripts. H. Specialty practice certification certificates. I. Verification of education/training. J. Statement of formal training for non-professionals. K. Orientation checklist (completed). L. Initial competency assessments. M. Signed job description. N. Condition of employment. O. Signed and dated confidentiality statement. P. Criminal background check and national sex offender registry, if applicable and a copy of the criminal record statement (LIC 508 form) (kept in separate file). A review of the HAs undated policy titled "Selection/Hiring of Personnel", indicated a criminal background check will be obtained for positions required by law, regulation, or organizational policy.