Every finding on record at Best Choice Hospice, Inc

Based on 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 inform the patients, of his or her rights, by providing written notice of information in a language the patient could understand and their rights to decline the hospice services, before admission, for three of seven patients (Patient 15, 17, and 18). This deficient practice resulted in the patient not informed and lack of understanding of the hospice agency's care and services, available for the patients and their family, and patients not able to exercise their right to decline the hospice services. (Refer to L 502). The HA failed to ensure the patients were informed and the agency explained all the Medicare (federal health insurance for people 65 or older) and non Medicare coverage for hospice service that patient could receive, and that the patient understand the information provided, for one of seven patients (Patient 16). 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 interview, and record review, the hospice agency (HA) failed to inform patients, of his or her rights, by providing written notice of information in a language the patient could understand and their rights to decline the hospice services, before admission, for three of seven patients (Patient 15, 17, and 18). This deficient practice resulted in the the patient not informed and lack of understanding of the hospice agency's care and services, available for the patients and their family, and patients not able to exercise their right to decline the hospice services. --- a. A review of Patient 15s Patient Information Sheet indicated a Start of Care (SOC) of 4/8/2022 with a primary diagnosis of acute combined systolic and diastolic congestive heart failure (heart disease where the heart cannot contract (squeeze) normally when the heart beats resulting in less blood circulating throughout the body and where the heart cannot relax, expand, or fill with enough blood). Patient 15s primary language was listed as Spanish. A review of Patient 15s Certification of Terminal Illness (CTI), Certification #5: Re-Certification Statement for Next 60-day period from 2/2/2023 to 4/2/2023 indicated Patient 15s primary diagnosis was acute combined systolic and diastolic congestive heart failure. On 2/22/2023 at 11:00 am, a joint home visit with Registered Nurse 1 (RN 1) was conducted at Patient 15s home residence. Patient 15 stated that he enrolled in hospice on 2/2/2023 and did not know he was enrolled in hospice last year in 2022. Patient 15 stated he was in hospice because he had prostate cancer. During an interview on 2/23/2023 2:35 pm, Registered Nurse (RN 2) stated she was not aware Patient 15 was a hospice patient when she first visited him on 2/2/2023. RN 2 stated Patient 15 did not have a hospice binder in his home, so she provided him a binder and filled out the consent forms required during a SOC admission. RN 2 stated she spoke some Spanish and was able to communicate with Patient 15 so he could understand her. A review of Patient 15s Informed Consent forms, dated 2/2/2023 were in English and signed by Patient 15. b. A review of Patient 17s Patient Information Sheet indicated Start of Care (SOC) date of 12/10/21, with a primary diagnosis of chronic obstructive pulmonary disease (COPD-lung disease that blocks airflow and makes it difficult to breathe). Patient 17s Primary language was documented as Spanish. A review of Patient 17s CTI #7, Re-certification Statement for the next 60-day period for 2/3/23 to 4/3/23, indicated that Patient 17 had a secondary diagnoses of hypertension (high blood pressure), abnormal heart beat, generalized muscle weakness, diabetes mellitus (disease of too much sugar in the blood), gastritis (inflammation of the lining of the stomach) and hyperlipidemia (high cholesterol- a fat like substance found in the blood that can limit blood flow and increase risk of heart attack or stroke). During a phone interview on 2/23/23, at 12:27pm, Patient 17 stated he has high blood pressure, high cholesterol and diabetes. Patient 17 stated he does not have a terminal illness and he does not know what hospice is. A review of Patient 17s Statement of Consent and Election Benefits, Patient Acknowledgement form, dated 2/10/21, were provided to the patient in English. It was documented that Patient 17's primary language was Spanish. c. A review of Patient 18s Patient Information sheet indicted a SOC date of 9/1/22, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain). Patient 18s primary language was documented as Spanish. A review of Patient 18s CTI # 2, Re-certification Statement for Second 90-day period, 11/30/22 to 2/27/23, indicated a secondary diagnosis of diabetes, hypertension and gastritis. During a phone interview on 2/23/23, at 1:45pm, Patient 18 stated that she was not terminally ill, and she does not know what hospice is. A review of Patient 18's Physician's Certification for Hospice Benefit from effective date of certification 9/1/22 to 11/29/22, indicated the referring physician was the HA's medical director 1 (MD 1). No information for Patient 18's primary physician could be found in the record. Patient 18s admission documents were provided in English, not Spanish which is documented as Patient 18s primary language.

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 service that patient could receive, and that the patient understand the information provided, for one of seven patients (Patient 16). This deficient practice resulted in the patients being misinformed about hospice care and services covered benefits. --- a. A review of Patient 16s Patient Information Sheet indicated a Start of Care (SOC) date of 7/6/2022 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). Caregiver (CGR 1) was listed as Patient 16s authorized representative/emergency Contact. A review of Patient 16s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/10/2023, indicated for a licensed vocational nurse (LVN) to visit twice per week and a Registered Nurse (RN) to visit once per month plus one PRN (as needed) visit. A review of Patient 16s Medicare Hospice Election Statement, dated 07/06/2022, indicated Patient 16 named Medical Director (MD 1) 1 for Hospice services. During an interview on 2/22/2023 at 10:16 am, CGR 1 stated he did not know Patient 16 and was not a caregiver to any patient. CGR 1 stated he previously worked for the HA but not since November 2022. CGR 1 stated the Owner sent him to get patient information such as medical information and addresses. During a telephone interview on 2/22/2023 at 3:06 pm, Patient 16 stated he is visited by a nurse who takes his vitals and his heart rate. Patient 16 denied having a terminal illness (an illness or condition which cannot be cured and is likely to lead to someone's death) and stated he just had diabetes. Patient 16 stated he could not remember what hospice meant. Patient 16 stated he had a hospice binder at home, signed admission paperwork, and verbalized that he was not dying and did not have a terminal illness. During a telephone interview with RN 2 and Patient 16 on 2/23/2023 at 2:55 pm, Patient 16 stated again he did not have a terminal illness and did not remember what hospice meant. Patient 16 stated he did not know who MD 1 was and that he needed to get another primary physician because his previous one left the clinic. 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 B. That the identification of the attending physician was the patient's/representative's choice.

Based on observation, 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 four of seven sampled patients, (Patients 15,16, 17 and 18). This deficient practice resulted in the provision of hospice services 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 for one of seven sampled patients, (Patients 15). 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). 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 observation, 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 four of seven sampled patients, (Patients 15,16, 17 and 18). This deficient practice resulted in the provision of hospice services who were not clinically eligible to receive hospice care and services. --- c. A review of Patient 17s Patient Information Sheet indicated a Start of Care (SOC) date of 12/10/21, with a primary diagnosis of chronic obstructive pulmonary disease (COPD-lung disease that blocks airflow and makes it difficult to breathe). Patient 17s Primary language was documented as Spanish. A review of Patient 17s re-certification assessment dated 2/2/23 indicated for Nature & Condition of Terminal Illness/ LCD(local coverage determination for hospice) Eligibility indicated Patient 17s illness trajectory and reason for hospice admission was pulmonary (lung) disease and that Patient 17 had shortness of breath, but refused O2 (oxygen) at the moment. A review of Patient 17s Local Coverage Determination (LCD) Hospice Eligibility Determination form indicated Patient 17 does not qualify per LCD guidelines. During a phone interview on 2/23/23, at 12:27pm, Patient 17 stated he has high blood pressure, high cholesterol and diabetes. Patient 17 stated he does not have a terminal illness. Patient 17 stated the nurses just come to his home check his blood pressure and his blood sugar. d. A review of Patient 18s Patient Information sheet indicted a SOC date of 9/1/22, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain). Patient 18s primary language was documented as Spanish. A review of Patient 18s CTI # 2, Re-certification Statement for Second 90-day period, 11/30/22 to 2/27/23, indicated a secondary diagnosis of diabetes, hypertension and gastritis. A review of Patient 18s Updated Nursing Assessment, dated 2/16/23, indicated Patient 18s illness trajectory and reason for hospice admission was heart disease and the patient had generalized weakness, required help to stand from chair and transferring to prevent falls and injury. Patient 18 also had multiple surgeries including hernia (a bulging of an organ or tissue through an abnormal opening) and colon surgery. A review of Patient 18s LCD Hospice Eligibility Determination form indicated Patient 18 does not qualify per LCD guidelines. During a phone interview on 2/23/23, at 1:45pm, Patient 18 stated she was not terminally ill and does not know what hospice is. During an interview on 2/23/23, at 2:23pm, Registered Nurse 2 (RN2), stated Patient 18 must be confused and forgetful because she explained to Patient 18 what hospice is. When asked what qualifies Patient 18 to be on hospice she said because "She has edema (swelling of extremities)." 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. A review of Patient 15s Patient Information Sheet indicated a Start of Care (SOC) date on 4/8/2022, with a primary diagnosis of acute combined systolic and diastolic congestive heart failure (heart disease where the heart cannot contract (squeeze) normally when the heart beats resulting in less blood circulating throughout the body and where the heart cannot relax, expand, or fill with enough blood). A review of Patient 15s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/10/2023, indicated for a licensed vocational nurse (LVN) to visit twice per week and a Registered Nurse (RN) to visit once per month plus two as needed (PRN) visits. A review of Patient 15s Recertification Comprehensive Assessment dated 2/2/2023 indicated Patient 15 was awake and alert, oriented to time, place and person, ambulatory with a cane, walker and required stand-by assistance. The comprehensive assessment indicated Patient 15 was easily fatigued after four to five steps, needed oxygen for shortness of breath, and indicated Patient 15 was imminently dying with symptoms of increased fatigue, sleeping or agitation and increased respiratory distress. A review of Patient 15s undated form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine Patient 15's eligibility for hospice services) for Heart Disease, , indicated Section 1 (Untreatable Condition) and Section 2 (New York Heart Association (NYHA) classification-a simple way of classifying the extent of heart failure and classifies patients in one of four categories based on their limitations during physical activity; the limitations/symptoms are in regards to normal breathing and varying degrees in shortness of breath and or angina pain) must be met. The LCD form indicated Patient 15 did not meet the criteria for NYHA 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. The LCD form indicated Patient 15s ejection fraction (EF, measurement of the amount of blood the left ventricle of the heart pumps out to your body with each heartbeat) was less than 20% (very severe heart failure). A review of Patient 15s medical records did not indicate Patient 15 had heart failure with reduced ejection fraction of less than 20%. On 2/22/2023 at 11:00 am, a joint home visit with Registered Nurse 1 (RN 1) was conducted at Patient 15s home residence. Patient 15 was observed on room air, walking in a slow steady gait from outside the patio area and into the inside of the house, about 10 to 15 steps with no walker or cane. Patient 15 sat on the couch and stated he was doing good, did not feel short of breath and did not need oxygen at this time. RN 1 performed vitals, checked for pain and edema, and performed a medication reconciliation. Patient 15 stated he leaves his house to go to the market with the caregiver every two weeks. Patient 15 stated he enrolled in hospice on 2/2/2023 and was not aware he was enrolled last year in 2022. Patient 15 stated the last time he was visited by a nurse was two weeks ago. During an interview on 2/23/2023 at 2:35 pm, RN 2 stated she performed Patient 15s Start of Care (SOC) on 2/2/2023. RN 2 stated she did not know that Patient 15 was a hospice patient when she first met him on 2/2/2023 and she was told by the Owner to see the patient and assess and evaluate to see if the patient quailed for hospice. RN 2 stated that during a comprehensive assessment she assessed the patient from head to foot, checked for mobility and edema, and relayed her assessment to the doctor, and requested for DME and medications. RN 2 stated Patient 15 was on hospice because of a diagnosis of prostate cancer. During an interview on 2/24/2023 at 1:00 pm with Primary Care Physician (PCP 1), PCP 1 stated that he was the primary care physician for Patient 15 since 9/14/2020 and that the last appointment with Patient 15 was on 2/1/2023. PCP 1 stated Patient 15s diagnoses included heart failure (when the heart cannot pump enough blood and oxygen to support other organs in your body), diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar), hypertension (high blood pressure), shoulder and lower back pain, and prostate cancer. PCP 1 stated Patient 15 has prostate cancer, but it is already controlled according to the Urologist [medical doctor who specializes in the diagnosis and treatment of and conditions of the urinary tract (kidneys, ureters, bladder and urethra)]. PCP 1 stated there was no hospice referral in Patient 15s medical chart and Patient 15 was not a terminally ill patient. b. A review of Patient 16's Patient Information Sheet indicated a Start of Care (SOC) date of 7/6/2022 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 16s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/10/2023 indicated for routine level of care, a licensed vocational nurse (LVN) would visit once per week, a Registered Nurse (RN) would visit once per month plus one as needed (PRN) visit, and a social worker (MSW) would visit once per month plus one visit, as needed (PRN), and a spiritual counselor (SC) would visit once per month plus one PRN visit. A review of Patient 16s Recertification Assessment dated 1/28/2023 indicated Patient 16 used a cane, walker and required moderate assistance when ambulating. The assessment indicated Patient 16s endurance was six steps before resting. Karnofsky Performance Status (KPS) of 50% (requires considerable assistance and frequent medical care), and a Palliative Performance Scale (PPS) of 50% (mainly sit/lie, cannot do any work, considerable assistance needed in self-care). The assessment indicated Patient 16 was alert and oriented to time, place, and person. The assessment indicated Patient 16 required assistance from the caregiver with activities of daily living because of increasing generalized weakness, poor endurance and fatigue. The assessment indicated RN provided caregiver teaching such as assess conditions that can increase the patients risk for fall and that the caregiver verbalized understanding. The assessment was signed by Registered Nurse (RN 2). During a telephone interview on 2/22/2023 at 2:51 p.m., Patient 16 stated he just came home from the shopping mall and was carrying bags inside his home. Patient 16 stated to called back in 15 minutes. During a telephone interview on 2/22/2023 at 3:06 pm, Patient 16 stated a nurse visits to take his blood pressure and heart rate. Patient 16 stated he just had diabetes, could not remember what hospice was, and that he was not dying or had a terminal illness. Patient 16 stated he needed to end the interview because he had to pick up his granddaughter. During a telephone interview with RN 2 and Patient 16 on 2/23/2023 at 2:55 pm, Patient 16 stated he did not have a terminal illness and did not remember what hospice meant. Patient 16 stated he did not know who MD 1 was and he needed to get another primary physician because his previous one left the clinic. During a concurrent interview and record review with RN 2 on 2/23/2023 at 3:20 pm, Patient 16s LCD Hospice Eligibility Determination indicated Patient 16 had an ejection fraction (EF, measurement of the amount of blood the left ventricle of the heart pumps out to your body with each heartbeat) of less than 20% (very severe heart failure). RN 2 stated the history and physical, could not be located in the patients clinical record. When RN 2 was asked how it was determined that Patient 16s ejection was less than 20%, RN 2 stated Patient 16 had told her. A review of the Hospice Agencys (undated) policy, Admission Criteria and Process, indicated that 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.

Based on observation, interview and record review, the Hospice Agency (HA) failed to review all medications and update the medication profiles with the currently used medications for one of seven sample (Patients 15). 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. --- A review of Patient 15s Patient Information Sheet indicated a Start of Care (SOC) date on 4/8/2022, with a primary diagnosis of acute combined systolic and diastolic congestive heart failure (heart disease where the heart cannot contract (squeeze) normally when the heart beats resulting in less blood circulating throughout the body and where the heart cannot relax, expand, or fill with enough blood). A review of Patient 15s Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less), Certification #5: Re-Certification Statement for Next 60-day period from 2/2/2023 to 4/2/2023 indicated Patient 15s primary diagnosis was acute combined systolic and diastolic congestive heart failure and secondary diagnoses including diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar) with diabetic neuropathy (damage to the nerves located outside of the brain and spinal cord which often causes weakness, numbness and pain), hypertension (high blood pressure), central pain syndrome (a neurological condition caused by damage to or dysfunction of the central nervous system and malignant neoplasm (cancer) of prostate (a small walnut-sized gland that produces seminal fluid). A review of Patient 15s Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/ Interdisciplinary Group Review (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 2/10/2023, indicated for a Licensed Vocational Nurse (LVN) to visit twice per week and a Registered Nurse (RN) to visit once per week. A review of Patient 15s Medication List indicated the following: o Tamsulosin Hydrochloride, 0.4 milligram (mg) capsule, one cap, oral, once a day for benign prostatic hyperplasia (BPH, a noncancerous enlargement of the prostate gland). o Hydrocodone Apap (acetaminophen), 10-325 mg, one tab, oral, every six hours as needed for pain. o Metformin Hydrochloride, 500 mg, two tabs, oral, every night (PM) for diabetes mellitus. On 2/22/2023 at 11:00 am, a joint home visit was conducted with Registered Nurse 1 (RN) at Patient 15s home residence. Patient 15 was observed on room air, walking in a slow steady gait from outside the patio area and into the inside of the house, about 10 to 15 steps with no walker or cane. Patient 15 sat on the couch and stated he was doing good, did not feel short of breath and did not need oxygen at this time. RN 1 performed vital signs, a skilled assessment, and a medication review. During the medication review with RN 1, the following was observed: o Tamsulosin, 0.4mg, take one capsule by mouth twice daily for BPH o Hydrocodone Apap (acetaminophen), 10-325 mg, one tab, oral, every six hours as needed for pain. o Metformin, 500 mg, take one tablet by mouth twice daily for diabetes. o Bupropion Hydrochloride SR 100 mg Extended Release tablet, take one tablet by mouth daily in the morning for depression was not on the medication list. o Trazadone Hydrochloride, 50 mg, take half a tablet by mouth every night as needed for sleep was not on the medication list. RN 1 stated the medication list should match the physical bottles of medications in Patient 15s home. During an interview and concurrent record review with RN 2 on 2/22/2022 at 1:49 p.m., Patient 15s medication and treatment worksheet dated 2/2/2023 was reviewed and indicated a new order for Norco 5-325 mg, one tab every eight hours for breakthrough pain and Ibuprofen 600 mg every eight hours for mild pain. RN 2 stated MD 1 changed Patient 15s pain medication order from Hydrocodone 10-325 mg to Norco 5-325 mg because it was too strong. RN 2 stated she sent the medication order to the pharmacist through HospiceMD (an accessible and secure web-based application used to manage, access and update patient electronic health records), however she was not able to locate the order. A review of the undated hospice policy titled, ";Medication Profile", indicated patients receiving medications administered by hospice will have a current, accurate medication profile. Medication profiles will be updated for each change to reflect current medications and new or discontinued medications.

Based on observation, interview and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, Coordination of Services was met as follows: The hospice agency Interdisciplinary Group (IDG) to review, revise, and document the individualized plan of care every 15 days for nursing, spiritual, psychosocial, or other/physician services for four of seven patients (Patient 15, 16, 17, and 18). This failure had the potential to result in the patients' care and services provided not being evaluated and updated to meet the needs and achieve the patients' care goals (refer to L 552). The hospice agency failed to provide license vocational nurse visits in accordance with the Plan of Care (POC) and did not notify the medical director of the missed visits for four of seven patients (Patient 15, 16, 17, and 18). This failure had the potential to affect the patient's medical needs and treatments (refer to L 554). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with the Federal regulations for the Interdisciplinary group, Care planning, and Coordination of services of patients to ensure hospice care and services were provided to meet the patient's care goals. --- .

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 four of seven sampled patients (Patients 15, 16, 17, and 18). This deficient practice resulted in the IDG not reviewing the patients care plans which had the potential to result in failure to identify changes in the patients progress and not updating the plan of care. --- c. A review of Patient 17s Patient Information Sheet indicated a start of care (SOC) date of 12/10/21, with a primary diagnosis of chronic obstructive pulmonary disease (COPD-lung disease that blocks airflow and makes it difficult to breathe). A review of Patient 17s plan of care (POC)/interdisciplinary group (IDG) review dated 1/31/23 for Certification #6 and 2/10/23 for certification #7, indicated IDG Discussion/Updated Comprehensive Assessment Review notes for nursing, spiritual care (the note indicated that Patient 17 declined services), psychosocial (note indicated that patient declined services) and other (i.e. volunteer and home health aide, which indicated Patient 17 declined). There was no note from the Medical Director. The documents only had an electronic signature for the registered nurse. d. A review of Patient 18s Patient Information sheet indicted a SOC date of 9/1/22, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain). A review of Patient 18s plan of care POC/ IDG review, dated 1/21/23 and 2/10/23 for certification #2, indicated IDG Discussion/Updated. Comprehensive Assessment Review notes for nursing, spiritual care (patient declined services), psychosocial (patient declined services) and other (patient declined volunteer and home care aid services. There was no note from the medical director. The document did not have an electronic signature for the medical director (MD), registered nurse (RN), social worker (MSW), or chaplain. During an interview on 2/23/23, at 4pm, the Owner stated they have been conducting IDG meetings, but they document on paper, not in their electronic charting system. The Owner stated she, the Registered Nurse 2 (RN 2), the medical director, social worker and chaplain all attended the meetings. A review of the HAs IGD meeting dates for 2023 schedule showed the following dates: 1/13/23,1/31/23, 2/8/23, 2/10/23 and 2/24/23. The HA only provided a paper copy of IDG minutes for 1/13/23 and the only signature present was that of the Owner. A review of the HAs policy titled ";Interdisciplinary Group Coordination of Care," dated 11/2020, 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 policy titled ";Interdisciplinary Group Meeting", dated 11/2020, 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. A review of Patient 15s Patient Profile indicated a Start of Care (SOC) on 4/8/2022, with a primary diagnosis of acute combined systolic and diastolic congestive heart failure (heart disease where the heart cannot contract (squeeze) normally when the heart beats resulting in less blood circulating throughout the body and where the heart cannot relax, expand, or fill with enough blood). A review of Patient 15s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 1/31/2023 and 2/10/2023, indicated for routine level of care, a licensed vocational nurse (LVN) would visit twice per week. A Registered Nurse (RN) would visit once per month, and a social worker (MSW) would visit once per month plus one visit as needed (PRN), and a spiritual counselor (SC) would visit once per month plus one PRN visit. The POC/IDG notes did not have any documented signatures from nursing, spiritual, psychosocial or physician core services. b. A review of Patient 16's Patient Profile indicated a Start of Care (SOC) date on 7/6/2022, 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 16s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 1/31/2023 indicated for routine level of care, a licensed vocational nurse (LVN) would visit once per week. A Registered Nurse (RN) would visit once per month plus one as needed (PRN) visit, and a social worker (MSW) would visit once per month plus one visit as needed (PRN), and a spiritual counselor (SC) would visit once per month plus one PRN visit. The POC/IDG notes did not have any documented signatures from spiritual, psychosocial or physician core services. A review of Patient 16s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/10/2023 indicated a routine level of care. A licensed vocational nurse (LVN) would visit once per week. A Registered Nurse (RN) would visit once per month plus one as needed (PRN) visit, and a social worker (MSW) visit once per month plus one visit as needed (PRN), and a spiritual counselor (SC) visit once per month plus one PRN visit. The POC/IDG notes did not have any documented signatures from nursing, spiritual, psychosocial or physician core services. A review of the hospice agency's policy titled, Interdisciplinary Group Meeting, dated 11/2020, indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. The policy indicated each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires.

Based observation, interview and record review, the hospice agency (HA) failed to ensure that nursing visits were conducted as scheduled per the plan of care for three of seven sampled patients (Patients 15, 16, and 18) and that the medical director was notified of the missed visits. The deficient practice had the potential to result in Patients 15, 16, and 18, to not receive adequate nursing care. --- c. A review of Patient 18s Patient Information sheet indicted a SOC date of 9/1/22, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain). A review of Patient 18s plan of care (POC)/interdisciplinary group (IDG) review, dated 2/10/23, indicated that Patient 18 was to have registered nurse (RN) visits every 14 days for supervisory visit and an ongoing comprehensive assessment, recertification and as needed for change of condition. Skilled nursing (SN) visits were to be conducted once per week and (once per week as needed for change of condition) for assessment, comfort, monitoring management. During a phone interview with Registered Nurse 2 (RN 2) on 2/23/23, at 1:45pm, Patient 18 stated she was currently in Mexico and has been there for the past two weeks. RN 2 stated she did not know Patient 18 was in Mexico. During an interview on 2/23/23, at 2:03pm, Registered Nurse 2, RN 2 stated she did not conduct a home visit on 2/16/23 and 2/21/23 because Patient 18 was not at home and only interviewed her over the phone. RN 2 stated when a home visit is missed, she has to notify the medical director (MD) right away and document in a nursing note. Patient 18s electronic medical record was reviewed. There was no communication notes documented with the MD notifying them of the missed visit, and there was no nursing notes indicating there was a missed visit. A review of the (undated) HAs policy titled ";Missed Visits" indicated if a visit is missed and not rescheduled the clinician will: A. Notify the IDG and clinical supervisor of the missed visit and reason for missed visit.B. Document in the patients clinical record the following information:1. Patient name.2. Date and type of visit that was missed.3. Reason for the missed visit.4. Description of any unmet needs and how the patients needs were met.5. Any other follow-up needed.6. Other person(s) that were notified of the missed visit.7. Signature of staff member reporting the information. a. A review of Patient 15s Patient Profile indicated a Start of Care (SOC) on 4/8/2022 with a primary diagnosis of acute combined systolic and diastolic congestive heart failure (heart disease where the heart cannot contract (squeeze) normally when the heart beats resulting in less blood circulating throughout the body and where the heart cannot relax, expand, or fill with enough blood). A review of Patient 15s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/10/2023, indicated a licensed vocational nurse (LVN) would visit twice per week and a Registered Nurse (RN) would visit once per month plus 2 as needed (PRN) visits. A review of Patient 15s clinical record indicated there were no skilled nursing visits performed by the LVN. Furthermore, there was no notification to the medical director that the LVN visit was missed. On 2/22/2023 at 11:00 am, a joint home visit with RN 1 was conducted at Patient 15s home residence. Patient 15 was observed on room air, walking in a slow steady gait from outside the patio area and into the inside of the house, about 10 to 15 steps with no walker or cane. Patient 15 sat on the couch and stated he did was doing good, did not feel short of breath and did not need oxygen at this time. RN 1 performed vital signs, skilled assessment, and medication review. b. A review of Patient 16's Patient Profile indicated a Start of Care (SOC) on 7/6/2022 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 16s POC/IDG Review, dated 2/10/2023, indicated for an LVN to visit twice per week and an RN to visit once per month plus one PRN visit. A review of Patient 16s clinical record indicated there were no skilled nursing visits performed by the LVN. Furthermore, there was no notification to the medical director that the LVN visit was missed. During an interview on 2/23/2023 at 5:29 p.m. RN 2 stated they currently do not have an LVN to visit the patients and have not notified the Medical Director (MD 1). RN 2 stated it was important to have an LVN visit the patient because the LVN performs an assessment of the patient, checks the patient medications, and reports any unusual conditions to the RN.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the governing body or the Administrator assumed full legal responsibility for the management of the hospice, the provision of all hospice services, continuous quality assessment and performance improvement, and appointed a qualified administrator and Director of Patient Care Services designee to run the day-to-day operation of the hospice. This deficiency had the potential to cause the hospice patients to receive inadequate hospice services. --- On 2/21/2023 at 11:15am, the HA was entered for an unannounced revisit survey. The only staff present was Clerk (CK 1). An entrance conference was conducted on 2/21/2023 at 12:30 pm with Registered Nurse (RN 1), RN 2 and Licensed Vocational Nurse (LVN 1). During a telephone interview on 2/21/2023 at 2:30 pm, the Administrator (ADM) stated she agreed to be the Administrator on 1/15/2023. The ADM stated she changed her mind about resigning as the ADM during the last recertification survey. The ADM stated she was not participating in the day-to-day operations of the HA and not coming to the office. The ADM stated she was only working on the CMS-2567 from the recertification survey. When asked if she had an employee file, ADM stated she did not have a file at the office yet. During an interview on 2/21/2023 at 3:02 pm, RN 1 stated she started working at the HA at the end of January and beginning of February 2023. RN 1 stated she had not met the ADM. During an interview on 2/21/2023 at 3:07 pm, LVN 1 stated he started working at the HA at the end of January and beginning of February 2023 and had not met, talked or seen the ADM at the office. During an interview on 2/21/2023 at 3:11 pm, RN 2 stated she started working at the HA on 1/17/2023 and had not met or seen the ADM at the office. During an interview on 2/21/2023 at 3:12 pm, the Clerk stated she worked at the office Monday through Friday, 9 am to 4 pm and had yet not met the ADM. During an interview on 2/21/2023 at 3:29 pm, the Owner stated she made the decision to hire the ADM but was not sure if the ADM wanted to resign again. The Owner stated she wanted to appoint the ADM officially but required the ADM to be at the office. The Owner stated that she could not appoint the ADM if her mind was unstable and stated that she did not have an official appointment letter for the ADM. During an observation on 2/21/2023 at 4:30 pm, the Administrator was not present at the HA during Day 1 of the Revisit survey. During an interview on 2/22/2023 at 11:30 am, the Owner stated she paid the ADM $20,000 to be the Administrator, but the ADM was not doing her job. The Owner stated the ADM never came to the office and told the Owner that the Administrator does not need to come into the office every day. The Owner stated that if she did not pay the ADM, then the ADM would not help her with the business and the Plan of Correction, so she paid her to be an Administrator, not a consultant. The Owner stated that she paid her other Administrators at her other hospice agencies a salary, but ADM kept pressuring her, so she paid her the money. The Owner stated that the ADM never submitted her paperwork. During an observation on 2/22/2023 at 5:00 pm, the Administrator was not present at the HA during Day 2 of the Revisit survey. During an observation on 2/23/2023 at 5:30 pm, the Administrator was not present for Day 3 of the Revisit survey and the Exit Conference. A review of the HAs policy titled ";Appointment of Executive Director/Administrator (policy No. 4-006.1), dated 11/2020, indicated the executive director/administrator of the hospice will be responsible for the day-to-day operations of hospice. A review of the HAs policy titled ";Designation of Individual in Absence of Executive Director/Administrator (policy no. 4-007.1), dated 11/2020, indicated that the HA will have an executive director/administrator or designee available at all times.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: 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 four of seven sample patients (Patients 15, 16, 17 and 18) by failing to: ensure Patients 15, 16, 17, and 18's recertification had the physician's documentation of clinical information (including current history and physician's, laboratory and imaging data biopsy results, etc.), conducted a face-to-face assessment of patient 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 observation, 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 four of seven sample patients (Patients 15, 16, 17, and 18) by failing to: Ensure that Patients 15,16,17 and 18s recertification had the physician's documentation of clinical information (including current history and physician's, laboratory and imaging data biopsy results, etc.), conducted a face-to-face assessment of 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 recertified 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. --- a. A review of Patient 15s Patient Information Sheet indicated a Start of Care (SOC) on 4/8/2022 with a primary diagnosis of acute combined systolic and diastolic congestive heart failure (heart disease where the heart cannot contract (squeeze) normally when the heart beats, resulting in less blood circulating throughout the body and where the heart cannot relax, expand, or fill with enough blood). A review of Patient 15s Certification of Terminal Illness (CTI), Certification #5: Re-Certification Statement for Next 60-day period from 2/2/2023 to 4/2/2023 indicated that Patient 15s primary diagnosis was acute combined systolic and diastolic congestive heart failure and that the certification was based on Face to Face Encounter. There was no date documented for the Face-to-Face encounter. The CTI Physician Narrative for the face-to-face summary was blank. The CTI Medical Director Attestation/Certification indicated the name of Medical Director (MD 3) but MD 3s signature was blank. There was no signature that attested or confirmed that Patient 15 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 2/22/2023 at 11:00 am, a joint home visit with Registered Nurse 1 (RN 1) was conducted at Patient 15s home residence. Patient 15 was observed on room air, walking in a slow steady gait from outside patio area and into inside of house, about 10 to 15 steps with no walker or cane. Patient sat on couch and stated he did was doing good, did not feel short of breath and did not need oxygen at this time. Patient 15 stated leaves his house to go to market with caregiver every two weeks. Patient 15 stated that he enrolled in hospice on 2/2/2023 and was not aware he was enrolled last year in 2022. Patient 15 stated a nurse has visited him every two weeks since in the beginning of February. b. A review of Patient 16s Patient Information Sheet indicated a Start of Care (SOC) on 7/6/2022 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 16s Certification of Terminal Illness (CTI), Certification #3: Re-Certification Statement for Next 60-day period from 1/2/2023 to 3/2/2023 indicated that Patient 16s primary diagnosis was a hypertensive heart disease (heart conditions caused by high blood pressure) without heart failure and secondary diagnoses including hypertension (high blood pressure) and diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). The CTI indicated that the certification was based on a face-to-face encounter, but no visit date was documented and the Physician Narrative for the face-to-face summary was blank. The CTI indicated the name of Medical Director (MD 1) as the Medical Director/Physician Designee to sign for Patient 16s recertification, however the signature/date was blank. During an interview on 2/21/2023 at 3:13 pm, MD 1 stated that she was the current medical director of the hospice agency. MD 1 stated she told the Owner not to add her name to any documentation without her knowledge. MD 1 stated she did not have access to the hospice agencys HospiceMD program (an accessible and secure web-based application used to manage, access and update patient electronic health records). MD 1 stated she did not recertify any patients since the last recertification survey in January 2023 because the patient files were missing documentation such as medical records from the patients previous physician. MD 1 stated that if the patient documentation was unable to be obtained, the patient should have been discharged. c. A review of Patient 17s Patient Information Sheet indicated a Start of Care (SOC) date of 12/10/21, with a primary diagnosis of chronic obstructive pulmonary disease (COPD-lung disease that blocks airflow and makes it difficult to breathe). A review of Patient 17s Certification of Terminal Illness (CTI) # 3, Re-certification Statement for next 60-day period, 6/8/22 to 8/6/22, indicated the registered nurse (RN) Prognosis Summary, the Physician Narrative: Face to Face Summary and the Certifying Physician Summary was blank. The CTI did not have a Medical Director Signature. A review of Patient 17s CTI #4, Re-certification Statement for next 60-day period, 8/7/22 to 10/5/22, indicated the registered nurse (RN) Prognosis Summary, the Physician Narrative: Face to Face Summary and the Certifying Physician Summary was blank. The CTI did not have a Medical Director Signature. A review of Patient 17s CTI # 5, Re-certification Statement for next 60-day period, 10/6/22 to 12/4/22, indicated the registered nurse (RN) Prognosis Summary, the Physician Narrative: Face to Face Summary and the Certifying Physician Summary was blank. The CTI did not have a Medical Director Signature. A review of Patient 17s CTI # 6, Re-certification Statement for next 60-day period, 12/5/22 to 2/2/23, did not have a Medical Director Signature. A review of Patient 17s CTI # 7, Re-certification Statement for next 60-day period, 2/3/23 to 4/3/23, did not have a Medical Director Signature. d. A review of Patient 18s Patient Information sheet indicted a SOC date of 9/1/22, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain). A review of Patient 18s CTI # 2, Re-certification Statement for Second 90-day period, 11/30/22 to 2/27/23, indicated the registered nurse (RN) Prognosis Summary and the Physician Narrative: Face to Face Summary was blank. The CTI did not have a Medical Director Signature. During an interview on 2/21/23, at 3:13pm, Medical Director 1 (MD 1), stated that she has not recertified any patients or signed any documents. She stated that she did not agree to re-certify any patients because the HA could not provide her with documentation and evidence that the patients qualified for hospice. A review of the hospice agencys policy titled Certification of Terminal Illness, (undated), 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 that 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 patient's medical record or, if applicable, examination of the patient. The policy indicated that the hospice physician or nurse practitioner must have a face-to-face encounter with the patient within the 30 days prior to the third benefit period recertification and within 30 days prior to each subsequent recertification.

Based on interview and record review, the hospice agency (HA) failed to maintain patient clinical records in accordance to federal guidelines as evidenced by the following. Entries in Patient 15 and 18's electronic medical record were not authentic and the Transfer of Medicare/Medi-Cal Hospice Benefit and Revocation Form for Patient 15 was signed at the start of care. (Refer L679) Discharge summaries for patients 19 and 21 were incomplete (refer to 684) 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 the highest quality of patient care are provided to the patients certified to receive hospice services. --- .

Based on record review and interview, the Hospice Agency (HA) failed to ensure documentation for two of seven sampled patients (Patient 15 and Patient 18) was accurate and authentic. This deficient practice resulted in the failure to document accurately and ensure authenticity of the patients clinical records. --- b. A review of Patient 18s Patient Information sheet indicted a Start of Care (SOC) date of 9/1/22, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain). A review of Patient 18s plan of care (POC)/interdisciplinary group (IDG) review, dated 2/10/23, indicated Patient 18 was to have registered nurse (RN) visits every 14 days for supervisory visits, ongoing comprehensive assessment and recertification and as needed for change of condition. Skilled nursing (SN) visits were to be conducted once per week and (once per week as needed for change of condition) for assessment, comfort and monitoring management. During a phone interview with Registered Nurse 2 (RN 2) on 2/23/23, at 1:45pm, Patient 18 stated that she was currently in Mexico and has been there for the past two weeks. RN 2 stated she did not know Patient 18 was in Mexico. A concurrent record review and interview was conducted with RN 2 on 2/23/23, at 2:03 p.m. of the Nurse Visit Route Sheet for Patient 18. The Route sheet indicated RN 2 conducted a telehealth visit (a visit conducted via phone call instead of in person) on 2/16/23 and 2/21/23. RN 2 stated Patient 18 was out of the house, so RN 2 just interviewed Patient 18 over the phone. A concurrent record review and interview was conducted with RN 2 on 2/23/23, at 2:10 pm of Patient 18s Updated Assessment dated 2/16/23. The document indicated a visit was conducted from 9:30 to 10:30. The narrative note stated ";RN visit and noted that Patient 18 was lying on the bed awake, alert, oriented and verbal. No complaints of pain reported. Vital signs checked and recorded. Noted with elevated BP 145/72 but asymptomatic. Patient denies any pain. Will recheck BP again before end of visit. Patient reported he gets easily tired and fatigued due to moderate to extensive activity. Instructed patient to facilitate brakes in between activities and able to verbalize understanding... bowel sounds active in all four quadrants. No Constipation or diarrhea reported. Skin assessment done; No skin impairment noted... infection control and COVID-19 precautionary measures observed throughout the visit. Hand washing done before and aftercare." The note was signed by RN 2. RN 2 was asked if she conducted this visit or not, because in her prior interview she stated she just interviewed the patient over the phone on 2/16/23 and Patient 18 stated that she had been in Mexico for the past two weeks. RN 2 stated, ";I do not know, I got confused." There was no RN visit note or assessment found for 2/21/23. A review of the HAs policy titled ";Entries into the Clinical Record", dated 11/2020, indicated documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical record will be clear, concise, and contain specific statements of fact. a. A review of Patient 15s Patient Information Sheet indicated a Start of Care (SOC) on 4/8/2022 with a primary diagnosis of acute combined systolic and diastolic congestive heart failure (heart disease where the heart cannot contract (squeeze) normally when the heart beats resulting in less blood circulating throughout the body and where the heart cannot relax, expand, or fill with enough blood). A review of Patient 15s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 2/10/2023, indicated for a licensed vocational nurse (LVN) visit twice per week and a Registered Nurse (RN) visit once per month plus two as needed (PRN) visits. During an interview on 2/23/2023 2:35 pm, Registered Nurse (RN 2) stated she was not aware Patient 15 was a hospice patient when she first visited him on 2/2/2023. RN 2 stated Patient 15 did not have a hospice binder in his home, so she filled out all the forms required during a SOC admission. During a concurrent interview and record review with Registered Nurse (RN 2) on 2/23/2023 at 2:37 pm, Patient 15s Updated Assessment dated 1/17/2023 indicated that RN 2 performed an assessment and signed on 2/21/2023. When RN 2 was asked how was it that an updated assessment dated on 1/17/2023 was completed by her if she met Patient 15 for the first time on 2/2/2023, RN 2 stated I dont know, I am confused. During a concurrent interview and record review with the Owner on 2/23/2023 at 2:39 pm, Patient 15s Updated Assessment dated 2/16/2023 indicated that the Owner signed to close the note on behalf of staff assigned on 2/21/2023. The Owner stated that she was not a clinician and that her signature must be a mistake. The Owner stated that the nurse should be the one signing the patients comprehensive assessment. During a concurrent interview and record review with the Registered Nurse (RN 2) on 2/23/2023 at 2:41 pm, Patient 15s Transfer of Medicare/Medi-Cal Hospice Benefit indicated that Patient 15 signed the document on 2/2/2023. RN 2 stated that she had Patient 15 sign the form just in case Patient 15 wanted to transfer to another hospice. When asked why it was filled out early, RN 2 stated that it would save time so we would not have to drive all the way to Patient 15s house. During a concurrent interview and record review with the Registered Nurse (RN 2) on 2/23/2023 at 2:42 pm, Patient 15s Revocation Form indicated that RN 2 and Patient 15 signed the document on 2/2/2023. RN 2 stated that the form was signed just in case Patient 15 wanted to revoke hospice. The Revocation form did not indicate a reason for revocation, and the name of person who confirmed revocation and date and time of revocation were blank. RN 2 stated that Patient 15 has not revoked hospice but if he did, we would document the name of the person who confirmed revocation and the date and time of the revocation.

Based on interview and record review, the hospice agency (HA) failed to complete discharge summaries for two of three sampled patients (Patient 19 and Patient 21). This deficient practice resulted in the status of the patients health condition at discharge to be unknown. --- a. A review of Patient 19s Patient Information Sheet indicated a Start of Care (SOC) date of 5/12/2022 and an end of service date (EOC-discharge date) of 01/6/2023, with a primary diagnosis of hypertensive heart disease with heart failure (a condition caused by high blood pressure that leads to the heart not being able to function properly). Patient 19s secondary diagnoses included diabetes (a condition where there is too much sugar in the blood) and osteoarthritis (a degenerative joint disease where the tissues in the joint breaks down). A review of Patient 19s Discharge plan, indicated that the Discharge plan was undated, there was no discharge reason indicated, and the nursing comments only said discharge (discharged). A review of Patient 19s Discharge summary indicated an EOC date of 1/6/2023 and reason for discharge was extended prognosis. There was no nursing narrative note. A review of Patient 19s electronic medical record (EMR) did not have any Interdisciplinary Group (IDG) notes related to the discharge nor any nursing visit notes. b. A review of Patient 21s Patient Information Sheet indicated an SOC date of 5/14/2022 and an EOC date of 1/8/2023. Patient 21 had a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain). Patient 21s secondary diagnosis included diabetes. A review of Patient 21s Discharge Plan was dated 1/8/2023, indicated a discharge reason of ";moved out of area". There were no nursing comments and the document indicated that the discharge was initiated by the family, but the discharge plan was not reviewed with and provided to patient/family/caregiver. A review of Patient 21s Discharge summary indicated an EOC date of 1/8/2023, and the reason for discharge indicated Patient 21 moved out of area. The nurses narrative note was empty. A review of Patient 21s electronic medical record (EMR) did not have any IDG notes related to the discharge. During an interview on 2/22/2023 at 2:52 pm, Registered nurse 1 (RN 1) stated Patient 21 was discharged on 1/18/2023, not on 1/8/2023 which was a misprint on the discharge summary. RN 1 stated she did not know that summary also needed to be added when discharging a patient. RN 1 thought that having the reason for discharge would be enough. During an interview on 2/22/2023 at 2:55 pm, Licensed Vocational Nurse 1 (LVN 1) stated all discharges should have discharge summary writing so you know why the patient was discharged and so you know what condition they were in at discharge. 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 review of the HAs (undated) policy titled ";Discharge Summary," indicated the hospice will complete necessary audits to determine completeness of the patients clinical record within 30 days of the last hospice visit and discharge date.

Based on interview and record review, the Hospice Agency (HA) failed to show proof that they developed an emergency preparedness plan (the staff knowledge, training, and capacities to participate, response during emergencies) and conducted in-services annually for the agency staff. This deficient practice had the potential to lead to employees suffering avoidable injuries in the event of an emergency situations. --- On 1/10/23, the Hospice Agency was unable to show proof that they had an emergency preparedness program. They could not provide proof of any in-services conducted. On 1/10/23, at 12:45pm, Registered Nurse 1 (RN1) could not find any documents to prove that any emergency drills were conducted. She stated that fire drills should be conducted annually, but she has not taken part in one. A review of the HAs policy titled ";Emergency Management: Emergency Management plan", (11/2020), indicated the organization will maintain an emergency preparedness communication plan that complies with Federal, State, and local laws and is reviewed and updated annually. The training is provided annually and demonstrates staff knowledge of emergency procedures. A review of the HAs (undated) policy titled ";Emergency Management: Table Top Exercise Protocol", indicated to ensure the agency is prepared for emergencies or disasters. Tabletop exercises may be used in place of one drill annually.

Based on observation, interview, and record review, the hospice agency failed to effectively explain what hospice is for six of 13 patients (Patient 2, 3, 4, 10, 12 and 13). This deficient practice resulted in the patients being misinformed about what hospice is and its purpose. --- d. A review of Patient 10s Patient Profile indicated a Start of Care (SOC) on 5/1/2022 with a primary diagnosis of unspecified diastolic congestive heart failure (condition in which your heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly). A review of Patient 10s Physicians Certification for Hospice Benefit for the first 90-day period, 5/1/2022 to 7/29/2022 indicated a terminal diagnosis for unspecified diastolic congestive heart failure. During an interview on 1/5/2022 at 3:43 pm, Patient 10 stated, she did not know what was meant by hospice and its benefits and there was no nurse from the hospice agency that visits her. e. A review of Patient 12s Patient Profile indicated a Start of Care (SOC) on 6/27/2022 with a primary diagnosis of heart disease (disease that can affect heart muscle, valves and blood vessels). A review of Patient 12s Physicians Certification for Hospice Benefit for certification period 6/27/2022 to 9/24/2022 indicated a terminal illness of heart disease. A review of Patient 12s Physicians Certification for Hospice Benefit indicated that Medical Director (MD 1) signed as the Referring Physician Attestation. A review of Patient 13s Patient Profile indicated a Start of Care (SOC) on 6/27/2022 with a primary diagnosis of seizures (a sudden, uncontrolled electrical disturbance in the brain). f. A review of Patient 13s Physicians Certification for Hospice Benefit for certification period 6/27/2022 to 9/24/2022 did not indicate a terminal diagnosis. A review of Patient 12s Physicians Certification for Hospice Benefit indicated that Medical Director (MD 1) signed as the Referring Physician Attestation. A review of Patient 13s Certificate of Terminal Illness (CTI #1) for certification period 6/27/2022 to 9/24/2022 did not indicate a terminal diagnosis. The CTI indicated in the RN Prognosis Summary that Patient 13 was a 62-year-old male with a history significant for mental retardation, Alzheimer-unspecified type of pathology, and dementia. The CTI indicated in the Certifying physician summary that ";per IDT discussion and recommendation, the patient was determined appropriate for hospice service" and signed by MD 1. During an interview on 1/6/2023 at 3:15 p.m., Caregiver (CGR 1) stated, a marketer for the hospice agency contacted him and told them that were able to get supplies for patients though the hospice program and that hospice no longer was just for terminally ill patients. CGR 1 stated he enrolled Patient 12 and Patient 13 in hospice so they could get supplies for them. CGR 1 stated that they received diapers, ensure (supplemental fluid), and medications. CGR 1 stated he made PCP 2 aware of this and PCP 2 stated that Patient 12 and Patient 13 should not be on hospice. CGR 1 stated that Patient 12 and 13 were on hospice for two months and called the hospice agency to take the patient off hospice in November or December 2022. During a telephone interview on 1/13/2023 at 11:23 am, Primary Care Physician (PCP 2) stated that he was not notified that Patient 12 and Patient 13 was placed in hospice care until December 2022. PCP 2 stated he was the primary physician for Patient 12 since 2015 and Patient 13 since 2013. PCP 2 stated that these patients were developmentally disabled, doing good and were not terminally ill. PCP 2 stated Patient 12 was 37 years old and had diagnoses of schizophrenia and dysphagia and did not have heart disease. PCP 2 stated Patient 13 had seizures, high blood pressure and an old myocardial infarction (MI, also known as a heart attack, is a life-threatening condition that occurs when blood flow to the heart muscle is abruptly cut off, causing tissue damage). PCP 2 stated these patients were not eligible for hospice and would not refer these patients for hospice care. a. A review of Patient 2s Patient Information Sheet, indicated a start of care (SOC) date of 8/1/22, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). Patient 2 had multiple secondary diagnoses with included essential primary hypertension (high blood pressure), chest pain and type 2 diabetes mellitus (high levels of sugar in the blood, where over time causes damage to the heart, blood vessels, eyes, kidneys and nerves). A review of Patient 2s "Physician's Certification for Hospice Benefit," (CTI) for the first 90- day period from 8/1/22-10/29/22, indicated a terminal diagnosis of hypertensive heart disease with heart failure. The CTI was signed by the HAs medical director (MD1), and did not indicate a communication between the HAs MD1 and Patient 2s primary care physician (PCP), validated that Patient 2 had a life expectancy of six months or less, if terminal illness ran its normal course. During an interview on 1/5/23 at 2:46 pm, Patient 2s family representative stated that they were not aware Patient 2 was on hospice care program and the hospice agency did not explained the hospice benefits and program. The family representative stated, Patient 2 has no terminal illness and was not dying. b. A review of Patients 3s Patient Information Sheet, indicated a SOC date of 5/13/22, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain), hypertension, coronary artery stent (surgical procedure to open up blocked arteries), rheumatoid arthritis (chronic inflammatory disease affecting the joints), chest pain and muscle weakness. A review of Patient 3s CTI for the first 90- day period from 5/13/22-8/10/22, indicated a terminal illness of atherosclerotic heart disease of native coronary artery without angina pectoris. The CTI was signed by the HAs medical director (MD2) and did not indicate any communication between the HAs MD2 and Patient 3s primary care physician (PCP) to validate that Patent 3 had a life expectancy of six months or less, if terminal illness ran its normal course. During an interview on 1/6/23, at 1:29 p.m., Patient 3 stated, she had no terminal illness, and had a diagnosis of heart disease. Patient 3 stated, the hospice agency was only assisted on providing supplies she needed. c. A review of Patient 4s Patient Information Sheet indicated a SOC date of 5/12/22, with primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris, chronic atrial fibrillation (an irregular, rapid heart rate that can cause poor blood flow), hypertension, coronary artery stent and chest pain. A review of Patient 4s CTI for the first 90- day period from 5/12/22-8/9/22, indicated a terminal illness of atherosclerotic heart disease of native coronary artery without angina pectoris. The CTI was signed by the HAs medical director (MD3) and did not indicate communication between the HAs MD3 and Patient 4s primary care physician (PCP) to validate that Patent 4 had a life expectancy of six months or less, if terminal illness ran its normal course. During an interview on 1/6/23, at 1:35 p.m., Patient 4 stated, had no terminal illness. Patient 4 stated, the hospice agency explained to him, that the hospice program would not had to be dying and but just related to services provided. Patient 4 stated, the hospice agency (HA) told him "You do not get regular nurse visitation and everyday needs are provided." Patient 4 stated, HA provided a nutritional drink, Boost or Ensure supplements, soap, and hand sanitizer. A review of the HA's policy titled "Rights and Responsibilities", dated 11/2020, indicated that the patient will be fully informed by a physician of his/or her medical condition.

Based on observation, 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 and document accurate comprehensive and Local Coverage Determination (LCD) assessment identifying the need for hospice care and services for three out of 13 sampled patients (Patients 11, 12, and 13). This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. This deficient practice resulted in patients not receiving health care and services, that includes routine check up and laboratory test, to maintain highest care and services to prevent illness. (Refer to L521). 2. The hospice agency (HA) failed to review all medications the patients were taking and update the medication profiles with the currently used medications for two of 13 sample selected patients (Patients 1 and 2). The deficient practice resulted in patients' not receiving medications as ordered by the physician that has a potential for the patients to experience adverse side effect if the medications were not administer timely. (Refer to L 530). The cumulative effect of these systemic practices resulted in the hospice agency inability to ensure the provision of quality health care services, admitting patients who did not meet admission criteria and did not qualify for the Medicare hospice benefit. --- .

Based on interview, and record review, the hospice agency failed to conduct an accurate comprehensive assessment that reflects the patients current health status and identify the patients needs for hospice care and services related to eligibility and management of the terminal illness for five of 13 sampled patients (Patients 3,4,10, 11, and 12). This deficient practice resulted in the provision of hospice services with anticipation of life expectancy of six months or less to Patients 3,4,10, 11, and 12, who were not clinically eligible to receive hospice care and services. --- c. A review of Patient 10s Patient Profile indicated a Start of Care (SOC) on 5/1/2022 with a primary diagnosis of unspecified diastolic congestive heart failure. A review of Patient 10s Initial Comprehensive Assessment dated 5/1/2022 indicated that no neurological, cardiovascular, respiratory, gastrointestinal, or genitourinary assessment was completed and was left blank. The Comprehensive Assessment was not signed by the RN. A review of Patient 10s (LCD) Hospice Eligibility Determination was not filled out and indicated that the ";Patient does not qualify per LCD Guidelines." d. A review of Patient 11s Patient Profile indicated an SOC of 5/15/2022 with a primary diagnosis of chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 11s Initial Comprehensive Assessment, dated 5/15/2022, did not indicate the nature and Condition of Terminal Illness/ LCD Eligibility and was left blank. The Comprehensive Assessment indicated that no neurological, cardiovascular, respiratory, gastrointestinal, or genitourinary assessment was performed. The Comprehensive Assessment was not signed by an RN. A review of Patient 11s (LCD) Hospice Eligibility Determination indicated it was not filled out and that the ";Patient does not qualify per LCD Guidelines." e. A review of Patient 12s Patient Profile indicated a Start of Care (SOC) on 6/27/2022 with a primary diagnosis of heart disease. A review of Patient 12s Initial Comprehensive Assessment dated 6/27/2022 indicated that the terminal stage determination for disease type was heart disease and the condition exist as reported by Patient caregiver/ Family. The cardiovascular assessment indicated no blood pressure symptoms, a regular apical pulse, no cardiac related pain, no edema (swelling caused by too much fluid trapped in the body's tissues) and no pitting edema (when pressure is applied to the swollen area, a ";pit", or indentation, will remain). The Comprehensive assessment indicated for a referral for social work, spiritual care and volunteer. The Initial Comprehensive assessment was not signed by an RN. A review of Patient 12s LCD Hospice Eligibility Determination indicated it was not filled out and that the ";Patient does not qualify per LCD Guidelines." A review of the Patient 12s Medication Profile dated 6/27/2022 indicated for one medication, metoprolol, 25mg, one tablet, oral once a day for hypertension. During an interview on 1/13/2023 at 11:23 am, Primary Physician (PCP 2) indicated that he had been the primary physician for Patient 12 since 2015 and visited the patient every eight to ten weeks. PCP 2 stated, the patient has no terminal illness and would not refer this patient to hospice care. PCP 2 stated Patient 12 did not have heart disease and was prescribed metoprolol to control his fast heart rate due to taking several psychotic medications. a. A review of Patients 3s Patient Information Sheet, indicated a SOC date of 5/13/22, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain). Other of Patient 3s diagnosis included hypertension, coronary artery stent (surgical procedure to open up blocked arteries), rheumatoid arthritis (chronic inflammatory disease affecting the joints), chest pain and muscle weakness. A review of Patient 3s CTI for the first 90- day period from 5/13/22-8/10/22, indicated a terminal illness of atherosclerotic heart disease of native coronary artery without angina pectoris. The CTI was signed by the HAs medical director (MD2) and did not indicate any communication between the HAs MD2 and Patient 3s primary care physician (PCP) to validate that Patent 3 had a life expectancy of six months or less, if terminal illness ran its normal course. A review of Patient 3s LCD Hospice Eligibility Determination was not filled out and indicated that ";Patient does not qualify per LCD Guidelines." During an interview on 1/6/23, at 1:29 p.m., Patient 3 stated, she has no terminal illness, and has heart disease. Patient 3 stated, the hospice agency (HA) was just providing supplies she needs. b. A review of Patient 4s Patient Information Sheet indicated a SOC date of 5/12/22, with primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Patient 4s secondary diagnoses include chronic atrial fibrillation (an irregular, rapid heart rate that can cause poor blood flow), hypertension, coronary artery stent and chest pain. A review of Patient 4s CTI for the first 90- day period from 5/12/22-8/9/22, indicated a terminal illness of atherosclerotic heart disease of native coronary artery without angina pectoris. The CTI was signed by the HAs medical director (MD3) and did not indicate any communication between the HAs MD3 and Patient 4s primary care physician (PCP) to validate that Patent 4 had a life expectancy of six months or less, if terminal illness ran its normal course. A review of Patient 4s LCD Hospice Eligibility Determination was not filled out and indicated that ";Patient does not qualify per LCD Guidelines." During an interview on 1/6/23, at 1:35 p.m., Patient 4 stated, he has no terminal illness. Patient 4 stated, the hospice agency (HA) had explained to him, "you do not have to be dying to be on hospice. It was just related to services provided. You do not get regular nurse visitation and everyday needs are provided." Patient 4 state, the HA provided nutritional drinks, Boost or Ensure supplements, soap, and hand sanitizer. During an interview on 1/13/23, at 11:38 am, PCP 1 stated that he was not aware that Patients 3 and 4 were signed up for hospice and did not refer the patients on hospice program.. PCP1 stated, Patient 3 and 4 should not be admitted on hospice program and services because the patients has no terminal illness. PCP 1 stated, Patients 3 and 4 were old and has multiple health problems, but they were stable.

Based on observation, interview and record review, the hospice agency (HA) failed to review all medications the patients were taking and update the medication profiles with the currently used medications for two of 13 sample selected patients (Patients 1 and 2). The deficient practice resulted in patients' not receiving medications as ordered by the physician that has a potential for the patients to experience adverse side effect if the medications were not administer timely. --- a. A review of Patient 1s Patient Information Sheet, indicated a re-admit start of care date (SOC) of 10/15/22, with a primary diagnosis of end stage heart failure (when the heart can no longer pump blood throughout the body adequately). No secondary diagnoses were listed. a. A review of Patient 1s "Physician's Certification for Hospice Benefit," (CTI) indicated that Patient 1 was currently on certification #6, dated 12/14/22-2/11/23. Secondary diagnoses included hypertension (HTN-high blood pressure), diabetes mellitus (DM-too much sugar in the blood that can lead to disorder of the kidneys, eyes, and heart), and epilepsy (brain disorder that causes uncontrollable body movements. Patient 1 did not have a plan of care, or medication profile added to the electronic medical record for the current certification period. A home visit was conducted on 1/9/23, at 10:15am, with Registered Nurse 1 (RN1), Patient 1 was currently taking the following medications... Metformin (medication for DM) 500 milligrams (mg-unit of measurement) take one tablet two times daily. Gabapentin (medication for nerve pain) 300mg. take one capsule three times a day. Atorvastatin (medication for high cholesterol) 10mg. Take one tablet at bedtime. Lisinopril (HTN medication) 20mg. take one tablet two times a day. Benztropine Mesylate (anti-psychotic) 1 mg. Take one tablet two time a day before meals. Bupropion Hydrochloride (anti-depressant) 100mg. Take half a tablet daily. Risperidone (anti-depressant) 4 mg. take one tablet two times a day as needed. During an interview in 1/9/23 at 10:15 a.m., RN 1 stated, Patient 1 has no medication profile and could not find on the electronic medical record. RN 1 stated, she did not know what happened. RN 1 stated, when she conducted a home visit to the patient, she would not take the patient's medication profile with her and she would just asked the patient if there were any updates. b. A review of Patient 2s Patient Information Sheet, indicated a start of care (SOC) date of 8/1/22, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). Patient 2 had multiple secondary diagnoses with included essential primary hypertension (high blood pressure), chest pain and type 2 diabetes mellitus (DM-high levels of sugar in the blood, where over time causes damage to the heart, blood vessels, eyes, kidneys and nerves). A review of Patient 2s CTI indicated they were on re-certification #2, dated 10/30/22-1/27/23. A review of Patient 2's "Current Treatment/Medication/DME" listed for order date 8/4/22, indicated that Patient 2was taking the following medications... Amidopine Besylate (HTN medication) 5mg. Take one tablet daily. Aspirin (Blood thinner/pain medication) 81 mg. Take one tablet daily. Atorvastatin (medication for high cholesterol) 10mg. Take one tablet daily. Celebrex (arthritis medication) 200mg. Take one capsule two times a day. Gabapentin (medication for nerve pain) 100mg. take two capsule two times a day. Metoprolol (HTN medication) 25mg, Take one tablet two times a day. A home visit was conducted on 1/6/23, at 11:20 a.m., with RN 1. During observation and review of the patient's medications, Patient 2 medication were not complete, and the following medications were the only available for the patients to take. Metoprolol (HTN medication) 25mg, Take one tablet two times a day. Metformin (medication for DM) 500 mg take one tablet two times daily. Anastrozole (breast cancer medication) 1mg. Take one tablet daily. Meclizine HCL (medication to treat dizziness) 25mg. Chew one tablet three times a day as needed. During an interview on 1/6/23, at 11:45am, RN1 stated, she did not know that Patient 1 had new medications. RN 1 stated that there were missing medications from the medication profile and was not available for the the patient. Patient 2 stated, she was only taking the current four medications she has. A review of the HA policy titled " Medication Profile", dated 11/2020, indicated that patients receiving medications administered by hospice will have a current, accurate medication profile. Medication profiles will be updated for each change to reflect current medications and new or discontinued medications.

Based on observation, interview and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, Coordination of Services was met as follows: The hospice agency failed to coordinate Interdisciplinary Group (IDG) meetings with the medical director to discuss the patients' needs related to the terminal illness and related conditions within two days of Start of Care (SOC), for eight of 13 patients (Patients 1, 2, 3, 4, 5, 10, 11, and 13). This failure had the potential to affect the patient's medical needs and treatments (refer to L 538). The hospice agency failed for the Interdisciplinary Group (IDG) to review, revise, and document the individualized plan of care every 15 days for nursing, spiritual, psychosocial, or other/physician services for five of 13 patients (Patient 10, 11, 12, 13, and 14). This failure had the potential to result in the patient's care and services provided not being evaluated and updated to meet the needs and achieve the patient's care goals (refer to L 552). The cumulative effect of these systemic practices resulted in the failure of the HA to delivery statutorily mandated compliance with the Federal regulations for Interdisciplinary group, Care planning, and Coordination of services of patients to ensure hospice care and services were provided to meet the patient's care goals. --- .

Based on record review and staff interview, the hospice agency (HA) failed to designate an interdisciplinary group (IDG), in consultation with the patients physician, in preparing the written plan of care (POC) within two days of Start of Care (SOC) for eight of 13 sampled patients (Patient 1, 2, 3, 4, 5, 10, 11, and 13). There was no evidence the physician was consulted in the development of the plan of care and the social worker, and Chaplain had participated in preparing the POC. This deficient practice could potentially prevent the patients from reaching their care planning goals. --- f. A review of Patient 10s Patient Profile indicated a Start of Care (SOC) on 5/1/2022 with a primary diagnosis of unspecified diastolic congestive heart failure (condition in which your heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly). A review of Patient 10s Physicians Certification for Hospice Benefit for the First 90-day period from 5/01/2022 to 7/29/2022 indicated a terminal diagnosis of unspecified diastolic congestive heart failure. A review of Patient 10s clinical record did not indicate any documented evidence that the IDG prepared a Plan of Care (POC) in consultation with the physician, nurse, MSW, and chaplain within two days of Patient 10s SOC. g. A review of Patient 11s Patient Profile indicated an SOC of 5/15/2022 with a primary diagnosis of chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 11s Physicians Certification for Hospice Benefit for the First 90-day period from 5/15/2022 to 8/12/2022 indicated a terminal diagnosis of Chronic Obstructive Pulmonary disease. A review of Patient 11s POC/IDG dated 5/15/2022 indicated routine level of care, LVN visit once per week plus one PRN visit and RN visit once per month plus one PRN visit and SC visit once a month plus one PRN visit. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain that participated in developing Patient 11's care plan. The POC/IDG note did not have any documented evidence of an IDG discussion, plan of care, or signatures from nursing, spiritual, psychosocial or physician core services. During a concurrent interview and record review with Registered Nurse (RN 1) on 1/6/2023 at 2:48 pm, Patient 11s IDG/POC was reviewed. RN 1 stated that Patient 10s POC was not updated and that she had so much to do that she forgot. h. A review of Patient 13s Patient Profile indicated a Start of Care (SOC) on 6/27/2022 with a primary diagnosis of seizures (a sudden, uncontrolled electrical disturbance in the brain). A review of Patient 13s Certificate of Terminal Illness (CTI #1) for certification period 6/27/2022 to 9/24/2022 indicated in the RN Prognosis Summary that Patient 13 was a 62-year-old male with a history significant for mental retardation, Alzheimer-unspecified type of pathology, and dementia. The CTI indicated in the Certifying physician summary that ";per IDT discussion and recommendation, the patient was determined appropriate for hospice service" and signed by MD 1. A review of Patient 13s POC/IDG dated 6/27/2022 indicated for routine level of care, LVN visit one a week plus one PRN visit, RN visit once a month plus one PRN visit, SC visit once a month plus on PRN visit. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain that participated in developing Patient 13's care plan. The POC/IDG note did not have any documented evidence of an IDG discussion, plan of care, or signatures from nursing, spiritual, psychosocial or physician core services. During an interview on 1/9/2023, at 12:07 pm the Owner stated that IDG meetings are done every two weeks and that it is written on paper then entered into the patient's electronic clinical record. The Owner was unable to provide any IDG documentation. During an interview on 1/9/2023 at 2:25 pm, Registered Nurse (RN1) stated that she did not know why POC/IDG notes for the patients were empty. RN 1 stated that IDG meetings were important to see how the patients were doing and make changes to the plan of care if it needed to be updated. A review of the hospice agency's policy titled the Plan of Care, dated 11/2020 indicated that the plan of care will identify the patient's needs and services to meet those needs, including the management of pain and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patient's and family/caregiver's needs. The policy further indicated that the individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care. a. A review of Patient 1s Patient Information Sheet, indicated a re-admit start of care date (SOC) of 10/15/22, with a primary diagnosis of end stage heart failure (when the heart can no longer pump blood throughout the body adequately. No secondary diagnoses were listed. A review of Patient 1s Physician's Certification for Hospice Benefit," (CTI) for the first 90- day period from 1/21/22-4/20/22 indicated a terminal diagnosis of end stage heart failure. Secondary diagnoses included hypertension (HTN-high blood pressure), diabetes mellitus (DM-too much sugar in the blood that can lead to disorder of the kidneys, eyes, and heart), and epilepsy (brain disorder that causes uncontrollable body movements. A review of Patient 1s current CTI indicated that they were on re-certification #6, for the certification period 12/14/22-2/11/23. A review of Patient 1s electronic medical record (EMR) did not have any interdisciplinary group (IDG) notes, nor was a plan of care (POC) created. b. A review of Patient 2s Patient Information Sheet, indicated a start of care (SOC) date of 8/1/22, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). Patient 2 had multiple secondary diagnoses with included essential primary hypertension (high blood pressure), chest pain and type 2 diabetes mellitus (DM-high levels of sugar in the blood, where over time causes damage to the heart, blood vessels, eyes, kidneys and nerves). A review of Patient 2s CTI indicated that they were on re-certification #2, for certification period 10/30/22-1/27/23. A review of Patient 2s electronic medical record (EMR) did not have any interdisciplinary group (IDG) notes. c. A review of Patients 3s Patient Information Sheet, indicated a SOC date of 5/13/22, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain). Other of Patient 3s diagnosis included hypertension, coronary artery stent (surgical procedure to open up blocked arteries), rheumatoid arthritis (chronic inflammatory disease affecting the joints), chest pain and muscle weakness. A review of Patient 3s CTI indicated that that they were on re-certification #4, for certification period 1/8/23-3/8/23. A review of Patient 3s ";POC/IDG Review" for the dates of 5/20/22, 6/3/22, 6/17/22, and 7/1/22 were incomplete. There was no documentation for IDG discussion/Updated Comprehensive assessment review for the following disciplines: nursing, spiritual, psychosocial or physician. The only POC problem/intervention/goals/status listed was pain, which was added on 5/13/22. Patient 3s other diagnoses were not indicated. There were no signatures for physician, nursing, social worker, or the chaplain. d. A review of Patient 4s Patient Information Sheet indicated a SOC date of 5/12/22, with primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Patient 4s secondary diagnoses include chronic atrial fibrillation (an irregular, rapid heart rate that can cause poor blood flow), hypertension, coronary artery stent and chest pain. Patient 4s most current CTI provided by the HA, indicated that they were on re-certification #3, dated 11/8/22-1/6/23. A review of Patient 4s ";POC/IDG Review" for the dates of 5/20/22, 6/3/22, 6/17/22, and 7/1/22 were incomplete. There was no documentation for IDG discussion/Updated Comprehensive assessment review for the following disciplines: nursing, spiritual, psychosocial or physician. The only POC problem/intervention/goals/status listed was pain, which was added on 5/17/22. Patient 4s other diagnoses were not indicated. There were no signatures for physician, nursing, medical social worker, or the chaplain. e. A review of Patient 5s Patient Information Sheet indicated a SOC date of 12/1/21, with primary diagnosis of hypertensive heart disease with heart failure, with secondary diagnosis of DM. A review of Patient 5s CTI, indicated that Patient 5 was on re-certification #6, dated 11/26/22-1/24/23. A review of Patient 5s ";POC/IDG Review" for the dates of 6/3/22, 6/17/22, and 7/1/22 were incomplete. There was no documentation for IDG discussion/Updated Comprehensive assessment review for the following disciplines: nursing, spiritual, psychosocial or physician and there were no signatures for physician, nursing, medical social worker, or the chaplain. During an interview on 1/9/23, at 12:07pm the Owner stated that IDG meeting are done every 2 weeks. states that it was done on paper, then we put in the EMR. The Owner stated she could not find the IDG papers with attendee signatures . The Owner stated that she attends the meeting, with the social worker, nurse, and chaplain. During an interview on 1/9/23, at 2:25pm Registered Nurse 1 (RN1) stated that she does not know why IDG notes for the patients are empty. RN 1 stated that they have IDG meetings to see how the patients are doing, and see if they need to make changes to pan of care. During an interview on 1/10/23 , at 12:45pm RN1 stated that the purpose of care plan is to have goals, and see if the patient is meeting those goals. If not then they need to make changes and other recommendation for patient. During an interview on 1/13/23, at 2:52pm, the Social worker (SW) stated that she never participated in an IDG meeting in person. She would write notes in patient charts and update the doctor if there were any issues.

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 for five of 13 sampled patients (Patients 10, 11, 12, 13, and 14). This deficient practice resulted in the IDG not reviewing the patients care plans which had the potential to result in failure to identify changes in the patients progress and not updating the plan of care. --- A review of Patient 10s Patient Profile indicated a Start of Care (SOC) on 5/1/2022 with a primary diagnosis of unspecified diastolic congestive heart failure (condition in which your heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly). A review of Patient 10s Physicians Certification for Hospice Benefit for the First 90-day period from 5/01/2022 to 7/29/2022 indicated a terminal diagnosis of unspecified diastolic congestive heart failure. A review of Patient 10s POC/IDG dated 5/20/2022, 6/3/2022, 6/17/2022, and 7/1/2022 indicated routine level of care. The frequency of visit by the Medical Director (MD), Registered Nurse (RN), Social Worker (SW), or Chaplain (SC) was left blank. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain that participated in developing Patient 11's care plan. The POC/IDG notes did not have any documented evidence of IDG discussion, comprehensive review, or signatures from nursing, spiritual, psychosocial or physician core services. There was no documented evidence of more IDG/POC notes in the Patient 10s clinical chart. A review of Patient 11s Patient Profile indicated an SOC of 5/15/2022 with a primary diagnosis of chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 11s Physicians Certification for Hospice Benefit for the First 90-day period from 5/15/2022 to 8/12/2022 indicated a terminal diagnosis of Chronic Obstructive Pulmonary disease. A review of Patient 11s POC/IDG dated 5/15/2022, 6/3/2022, 6/17/2022, and 7/1/2022 indicated routine level of care, LVN visit once per week plus one PRN visit and RN visit once per month plus one PRN visit and SC visit once a month plus one PRN visit. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain that participated in developing Patient 11's care plan. The POC/IDG notes did not have any documented evidence of IDG discussion, comprehensive review, or signatures from nursing, spiritual, psychosocial or physician core services. There was no documented evidence of more IDG/POC notes in the Patient 11s clinical chart. A review of Patient 12s Patient Profile indicated a Start of Care (SOC) on 6/27/2022 with a primary diagnosis of heart disease (disease that can affect heart muscle, valves and blood vessels). A review of Patient 12s Certificate of Terminal Illness (CTI #1) for certification period 6/27/2022 to 9/24/2022 indicated a primary diagnosis of heart disease. A review of Patient 12s POC/IDG dated 6/27/2022 indicated for routine level of care, LVN visit one a month plus one PRN visit, RN visit once a month plus one PRN visit, SC visit once a month plus an PRN visit and volunteer visit once a month plus one PRN visit. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain that participated in developing Patient 12's care plan. The POC/IDG notes did not have any documented evidence of IDG discussion, comprehensive review, or signatures from nursing, spiritual, psychosocial or physician core services. There was no documented evidence of more IDG/POC notes in the Patient 12s clinical chart. A review of Patient 13s Patient Profile indicated a Start of Care (SOC) on 6/27/2022 with a primary diagnosis of seizures (a sudden, uncontrolled electrical disturbance in the brain). A review of Patient 13s Certificate of Terminal Illness (CTI #1) for certification period 6/27/2022 to 9/24/2022 did not indicate a terminal diagnosis. The CTI indicated in the RN Prognosis Summary that Patient 13 was a 62-year-old male with a history significant for mental retardation, Alzheimer-unspecified type of pathology, and dementia. The CTI indicated in the Certifying physician summary that ";per IDT discussion and recommendation, the patient was determined appropriate for hospice service" and signed by MD 1. A review of Patient 13s POC/IDG dated 6/27/2022 and 7/1/2022 indicated for routine level of care, LVN visit one a week plus one PRN visit, RN visit once a month plus one PRN visit, SC visit once a month plus on PRN visit. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain that participated in developing Patient 13's care plan. The POC/IDG notes did not have any documented evidence of IDG discussion, comprehensive review, or signatures from nursing, spiritual, psychosocial or physician core services. There was no documented evidence of more IDG/POC notes in the Patient 13s clinical chart. A review of Patient 14s Patient Profile indicated a Start of Care (SOC) on 4/7/2022 with a primary diagnosis of atherosclerosis heart disease of native coronary artery (hardening of the heart arteries) without angina pectoris (chest pain). The Patient Profile indicated that Patient 14 was a re-admit and starting on certification #3. A review of Patient 14s Physicians Certificate for Hospice Benefit for Certification of Terminal Illness (CTI #3) for certification period 04/07/2022 to 6/05/2022 indicated Patient 14s terminal diagnosis of atherosclerosis heart disease of native coronary artery without angina pectoris. A review of Patient 14s POC/IDG dated 6/3/2022, 6/17/2022 and 7/1/2022 indicated for routine level of care, an LVN visit twice a week plus one PRN visit, a RN visit once a month plus one PRN visit, and an SC visit once a month plus on PRN visit. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain that participated in developing Patient 14's care plan. The POC/IDG notes did not have any documented evidence of IDG discussion, comprehensive review, or signatures from nursing, spiritual, psychosocial or physician core services. There was no documented evidence of more IDG/POC notes in the Patient 14s clinical chart. During an interview on 1/9/2023, at 12:07 pm the Owner stated that IDG meetings are done every two weeks and that it is written on paper then entered into the patient's electronic clinical record. The Owner was unable to provide any IDG documentation. During an interview on 1/9/2023 at 2:25 pm, Registered Nurse (RN1) stated that she did not know why POC/IDG notes for the patients were empty. RN 1 stated that IDG meetings were important to see how the patients were doing and make changes to the plan of care if it needed to be updated. A review of the hospice agency's policy titled, Interdisciplinary Group Meeting, dated 11/2020, indicated that interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. The policy indicated that each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires.

Based on interview and record review, the hospice agency (HA) failed to ensure all care services furnished followed individualized plans of care established by the interdisciplinary team (IDT) for three of 13 sample patients (Patient 11, 12, and 14). This deficient practice resulted in the patients not receiving the care/services from the home visits and placed the patients at risk of not being provided care/services they needed. --- a. A review of Patient 11s Patient Profile indicated a SOC of 5/15/2022 with a primary diagnosis of chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 11s POC/IDG dated 7/1/2022 indicated for routine level of care and for an LVN to visit Patient 11 once per week plus one PRN visit, an RN visit once per month plus one PRN visit, and a SC visit once per month plus one PRN visit. The POC/IDG listed Registered Nurse (RN 1) and Licensed Vocational Nurse (LVN 2) as Patient 11s assigned hospice nursing staff. A review of Patient 11s clinical record indicated there was no documented evidence the RN visited the Patient in the month of December 2022 (12/2022) and the LVN visited the patient from 10/5/2022 through 12/2022. During an interview on 1/13/2023 at 4:57 pm, LVN 2 stated he worked for the hospice agency from April 2022 until June 2022. LVN 2 stated the agency assigned him patients that were not dying and not suitable for hospice. LVN 2 stated that the hospice agency kept adding patients to his assignment and he told them he was not able to visit 30-40 patients because he still worked full time at a hospital. LVN 2 stated he stopped taking patients and working for the hospice agency in June 2022. LVN 2 was not aware that he was still being assigned hospice patients. b. A review of Patient 12s Patient Profile indicated a Start of Care (SOC) on 6/27/2022 with a primary diagnosis of heart disease (disease that can affect heart muscle, valves and blood vessels). A review of Patient 12s POC/IDG dated 6/27/2022 indicated a routine level of care, which entailed the LVN visit one a month plus one PRN visit, RN visit once a month plus one PRN visit, SC visit once a month plus one PRN visit and volunteer visit once a month plus one PRN visit. The POC/IDG listed Registered Nurse (RN 1) and Licensed Vocational Nurse (LVN 1) as Patient 11s assigned hospice nursing staff. A review of Patient 12s RN visit note dated 12/6/2022 and 12/11/2022 indicated no documented evidence of vitals signs and was signed by RN 1. A review of Patient 12s clinical chart did not indicate any documented evidence that LVN 1 visited once a month from 11/2022 through 12/2022. c. A review of Patient 14s Patient Profile indicated a Start of Care (SOC) on 4/7/2022 with a primary diagnosis of atherosclerosis heart disease of native coronary artery (hardening of the heart arteries) without angina pectoris (chest pain). The Patient Profile indicated that Patient 14 was a re-admit and starting on certification #3. A review of Patient 14s POC/IDG dated 7/1/2022 indicated a routine level of care, which entailed an LVN visit twice a week plus one PRN visit, a RN visit once a month plus one PRN visit, and an SC visit once a month plus one PRN visit. The POC/IDG listed LVN 1 and RN 1 as Patient 14s assigned hospice nursing staff. A review of Patient 14s RN Visit Note dated 12/12/2022 indicated no documented evidence of vital signs and was not signed by RN 1. A review of Patient 14s RN Visit Note dated 11/21/2022, 11/25/2022, 11/26/2022, and 12/12/2022 were not signed by RN 1. A review of Patient 14s clinical chart did not indicate any documented evidence that an LVN visited two times per week from 11/21/2022 through 12/2022. During an interview on 1/12/2023 at 11:05 am, LVN 1 stated that he applied to the hospice agency a long time ago but did not finish his application or provide his credentials. LVN 1 stated that he never worked for the hospice agency and never saw any patients. LVN 1 stated he did not know why there were notes with his name in the patient clinical charts. During an interview on 1/13/2023 at 2:25 pm, RN 1 stated that she did not visit every patient weekly. RN 1 stated the SN visit depended on the patient and their needs. RN 1 was not aware if there was another nurse that visited the patients. RN 1 stated she did not know how to retrieve and check documentation or put clinical notes in the patients electronic chart in Hospice MD (an accessible and secure web-based application used to manage, access and update patient electronic health records). A review of the agency's policy and procedure titled, "Plan of Care" revised in November 2017 indicated the care provided to the patient would be in accordance with the plan of care.

Based on interview and record review the hospice agency (HA) failed to develop, implement, and maintain an effective, ongoing, hospice-wide data-driven quality assessment and performance improvement program. This deficient practice resulted in the hospice agency lack of quality measures on developing patient care plan and and agency's performance improvement. --- During an interview on 1/13/23, at 4:45 p.m., the owner stated that QAPI meeting were conducted quarterly, but she did not know where the office staff put the minutes from the meetings. A review of the HAs Quality Assessment and Performance Improvement (QAPI) Plan, (undated), indicated that the QAPI committee will meet quarterly and will be composed of representatives from the following: 1. Governing Board 2. Director of patient care services/clinical director designee 3. Administrator 4. Nursing services 5. Social Services 6. Medical director 7. Spiritual Counselor The QAPI chairman will present a quarterly report that will include a summary of the previous three months QAPI activities, problems identified, problem resolved, as well as recommendations for policy/procedure changes. A review of the HAs QAPI plan: ";Program Compliance Review", (undated), indicated that the hospice agency will assure accountability of the hospice management team for compliance with all appropriate requirement through a system of monthly meeting and regular reporting. A monthly meeting will be established to provide the administration and the governing body with key data about the status of the hospice program. All participants will sign-in for each meeting. Minutes of the meeting will be maintained.

Based on record review and interview, the Hospice Agency (HA) failed to show proof that staff received in-services (education) for infection control related to Covid-19 (Coronavirus disease, a severe respiratory illness caused by a virus and spread from person to person) and other infectious organisms on an annual basis. The agency did not keep sign-in logs of staff that attended in-services. Due to this deficient practice, the HA could not validate which staff member received the in-service. This could lead to the spread of Covid-19 and other infections if they did not receive the proper training. --- On 1/10/23, the HA was unable to show proof that they provided infection control in-services to staff on an annual basis. The HAs Infection Control Binder was reviewed and did not have any in-services conducted. On 1/10/23, at 12:45pm, Registered Nurse 1 (RN1) stated she remembers having an in-service on Covid-19, but she was unable to show any proof of that in-service. RN1 stated that it is important to conduct infection control in-services to educate staff on how not to spread infections like Covid-19. A review of the HAs (undated) policy titled ";Infection Prevention and Control (Policy No. 9-001.5)", , it indicated that infection control in-services will be scheduled no less than annually. Attendance will be mandatory and will be documented. Records of in-service attendance will be maintained in the personnel file.

Based on interview and record review the facility failed to provide spiritual counseling in accordance with the patient/family's desires for four out of 13 sample selected patients (Patients 9, 11, 12, and 13). This failure has the potential risk for patients and their family's spiritual needs to not be met. --- a. A review of Patient 9's Patient Profile indicated a Start of Care (SOC) on 12/19/2021, with a primary diagnosis of hypertensive heart disease without heart failure. A review of Patient 9s initial comprehensive assessment dated 12/19/2021 indicated Patient 9 was awake and alert, oriented to time, place and person, was ambulatory with a walker and required stand-by assistance. The comprehensive assessment indicated referrals for social work and spiritual care. There was no documented evidence of a spiritual assessment for Patient 9. A review of Patient 9s Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/1/2022, indicated a licensed vocational nurse (LVN) would visit twice a week plus one visit as needed (PRN), a registered nurse (RN) visit once per week plus two visits PRN, and a spiritual counselor (SC) visit once every two weeks plus three visits PRN. There was no documented evidence of a spiritual counselor (SC) visit note for Patient 9. b. A review of Patient 11s Patient Profile indicated a SOC of 5/15/2022 with a primary diagnosis of chronic obstructive pulmonary disease (COPD, a chronic inflammatory lung disease that causes obstructed airflow from the lungs). A review of Patient 11s Initial Comprehensive Assessment, dated 5/15/2022, indicated a referral for social work and spiritual care. There was no documented evidence of a spiritual assessment for Patient 11. A review of Patient 11s POC dated 1/6/2023 indicated a routine level of care and for an LVN to visit Patient 11 once per week plus one PRN visit, an RN visit once per month plus one PRN visit, and a SC visit once per month plus one PRN visit. There was no documented evidence of SC visit notes for Patient 11. c. A review of Patient 12s Patient Profile indicated a Start of Care (SOC) on 6/27/2022 with a primary diagnosis of heart disease. A review of Patient 12s Initial comprehensive assessment dated 6/27/2022, indicated a referral for social work, spiritual care and volunteer. There was no documented evidence of a spiritual assessment for Patient 12. A review of Patient 12s POC/IDG dated 6/27/2022 indicated a routine level of care for Patient 12, which entailed an LVN visit one a month plus one PRN visit, RN visit once a month plus one PRN visit, SC visit once a month plus on PRN visit and volunteer visit once a month plus one PRN visit. There was no documented evidence of SC visit notes for Patient 12. During an interview on 1/6/2023 at 3:15 pm, Caregiver 1 (CGR 1) stated the chaplain did not come to the Adult Residential facility to visit Patient 12 and Patient 13. d. A review of Patient 13s Patient Profile indicated a Start of Care (SOC) on 6/27/2022 with a primary diagnosis of other seizures. A review of Patient 13s Initial comprehensive assessment dated 6/27/2022 indicated a referral for social work, spiritual care and volunteer. There was no documented evidence of a spiritual assessment for Patient 13. A review of Patient 13s POC/IDG dated 6/27/2022 and 7/1/2022 indicated a routine level of care for Patient 13, which entailed an LVN visit one a week plus one PRN visit, RN visit once a month plus one PRN visit, SC visit once a month plus one PRN visit. There was no documented evidence of SC visit notes for Patient 13. During an interview on 1/6/2023 at 3:15 pm, Caregiver 1 (CGR 1) stated no chaplain had come to the Adult Residential facility to visit Patient 12 and Patient 13. During a concurrent telephone interview and record review on 1/5/2022 at 4:15 pm, the Hospice agencys employee roster was reviewed. The Spiritual Counselor (SC) stated he was not the chaplain for the Hospice Agency, had never worked with the Hospice agency, and was unaware on how the Hospice Agency had his information. The SC stated he worked for multiple hospice agencies, but this was not one of them. A review of the Hospice Agencys policy titled, "Spiritual are Counseling Services", dated 11/2020, indicated the Hospice will provide spiritual care counseling in keeping with the patient's and family/caregiver's belief system and practice, and in accordance with the plan of care. The policy indicated that the Hospice Chaplain (or designated spiritual care counselor) will provide direct support and coordinate services utilizing local clergy and other individuals, as appropriate. The policy indicated the chaplain will be assigned to each patient based on the patient's needs and acceptance of these services. The chaplain will be a member of the interdisciplinary group and will participate in the development, implementation and revision of the plan of care.

Based on interview and record review, the Hospice Agency (HA) failed to ensure a qualified volunteer coordinator was hired to oversee the volunteer services program. The deficient practice failed to facilitate compliance with the core services requirement. --- On 1/5/23, at 11:00am, an entrance conference was conducted via telephone with the HAs owner. The owner listed workman 1 as the volunteer coordinator. During an interview on 1/5/23, at 2:25pm, Workman 1 stated he was not the volunteer coordinator, he stated he helps with fixing thing at the office, like the plumbing. Workman 1 stated a couple of days ago the owner asked him about volunteering, and he stated he would think about it. Workman 1 stated he has not filled out an application or signed any paperwork. A review of the HAs organizational chart did not have a name listed for a volunteer coordinator. During an interview on 1/9/23, at 2:17 p.m., the owner stated she was not using volunteer services because all patients refused. When asked what her plan was if a patient did request volunteer services, the owner was not able to give plan. A review of the HAs policy titled ";Volunteer Services (Policy no. 2-009.1)". Dated 11/2020, indicated the HA will provide volunteer services under the direction of a volunteer coordinator and with assistance of trained hospice volunteers. The volunteer coordinator will develop, implement, and regularly evaluate the volunteer services program, at least annually.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the governing body or the Administrator assumed full legal responsibility for the management of the hospice, the provision of all hospice services, continuous quality assessment and performance improvement, and appointed a qualified administrator and Director of Patient Care Services designee to run the day to day operation of the hospice. This deficiency had the potential to cause the hospice patients to receives inadequate hospice services. --- On 1/5/23, at 11:00 a.m., the HA was entered for an unannounced recertification survey. The only staff present was Worker 1, who was there to fix the plumbing. Worker 1 called the owner via telephone. An entrance conference was conducted via telephone with the HAs owner on 1/5/23, at 11:00 a.m. due to the owner being sick, and unable to come to the office. The owner stated Administrator 1 (ADMN 1) was on vacation, so ADMN 2 was the designee. ADMN 2 was sick, and unable to come to the office, there was no other designee at the time. During a telephone interview on 1/5/23, at 11:15am, ADMN 2 stated she just agreed to act as administrator designee a couple of days ago, but she has not officially done any administrator work yet. She was not familiar with any patients and could not provide any information about them. ADMN 2 stated the Director of Patient Care Services (DPCS) designee was Registered Nurse 1 (RN1). ADMN 2 stated she would call RN 1 have her come to the office. During a telephone interview on 1/5/23, at 2:31pm, RN1 stated she was the registered nurse who conducted home visits for the HA. RN1 stated the Owner called her and asked her to come into the office, but she was currently out in the field, and did not know what time she would be in. On 1/5/23, at 4:30pm, no staff member ever came to the office to assist. On 1/5/23, at 8:24pm, ADMN 2 called and informed me effective immediately she will no longer be the administrator designee. ADMN 2 stated there should always be a staff member in the office, and there should have been someone at the office to assist us today. On 1/9/23, at 11:54am, the Owner still said ADMN 2 was the administrator designee. The Owner was unable to reach ADMN 2 via phone, when asked who the next designee in line was, the Owner stated RN1. The Owner was not able to provide any governing body minutes showing RN 1 was appointed as DPCS designee. A review of the HAs organizational chart did not have RN 1 listed as the DPCS designee. A review of the HAs policy titled ";Appointment of Executive Director/Administrator (policy No. 4-006.1), dated 11/2020, indicated the executive director/administrator of the hospice will be responsible for the day-to-day operations of hospice. A review of the HAs policy titled ";Designation of Individual in Absence of Executive Director/Administrator (policy no. 4-007.1), dated 11/2020, indicated that the HA will have an executive director/administrator or designee available at all times.

Based on observation, 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, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications of four of 13 sample patients, (Patients 3, 4, 12 and 13) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. (Refer to L 667) 2. 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 10 of 13 sample patients (Patients 1, 2, 3, 4, 5, 9, 10, 12, 13, and 14) by failing to: ensure that Patients 1, 2, 3, 4, 5, 9, 10, 12, 13, and 14s recertification has the physician's documentation of clinical information (including current history and physician's, laboratory and imaging data biopsy results, etc.), conducted a face-to-face assessment of patient 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 observation, interview, and record review, the hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications of four of 13 sample patients, (Patients 3, 4, 12 and 13) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. 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. --- c. A review of Patient 12s Patient Profile indicated a Start of Care (SOC) on 6/27/2022 with a primary diagnosis of heart disease (disease that can affect heart muscle, valves and blood vessels). A review of Patient 12s Physicians Certification for Hospice Benefit, dated 6/27/2022, indicated Medical Director (MD 1) signed on the Referring Physician Attestation that ";This patient has a life expectancy of six months or less, if the terminal illness runs its normal course." The document had no documented evidence that the hospice medical director or the hospice attending physician, communicated with the patient's primary physician, to certify Patient 12 had a life expectancy of six months or less, "If the terminal illness runs its normal course." A review of Patient 12s Certificate of Terminal Illness (CTI #1) for certification period 6/27/2022 to 9/24/2022 indicated a primary diagnosis of heart disease. The CTI indicated in the RN Prognosis Summary that Patient 12 was a 36-year-old male with a history significant for mental retardation, anxiety disorder and essential hypertension. The CTI indicated in the Certifying physician summary per IDT discussion and recommendation, the patient was determined appropriate for hospice service and signed by MD 1. There was no documented evidence of history and physical or diagnostic results or face to face for Patient12. There was no documented evidence the Hospice Medical Director communicated with Patient 12s Primary Care Physician (PCP 2). A review of the Patient 12s Medication Profile dated 6/27/2022 indicated for one medication, metoprolol, 25mg, one tablet, oral once a day for hypertension. d. A review of Patient 13s Patient Profile indicated a Start of Care (SOC) on 6/27/2022 with a primary diagnosis of seizures (a sudden, uncontrolled electrical disturbance in the brain). A review of Patient 13s Physicians Certification for Hospice Benefit indicated the Medical Director (MD 1) signed as the Referring Physician Attestation that ";This patient has a life expectancy of six months or less, if the terminal illness runs its normal course." The document had no documented evidence, that the hospice medical director or the hospice attending physician, communicated with the patient's primary physician, to certify that Patient 13 had a life expectancy of six months or less, "if the terminal illness runs its normal course." A review of Patient 13s Certificate of Terminal Illness (CTI #1) for certification period 6/27/2022 to 9/24/2022 did not indicate a terminal diagnosis. The CTI indicated in the RN Prognosis Summary that Patient 13 was a 62-year-old male with a history significant for mental retardation (cognitive ability that is markedly below average level and a decreased ability to adapt to one's environment), Alzheimer disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) -unspecified type of pathology, and dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities). The CTI indicated in the Certifying physician summary that ";per IDT discussion and recommendation, the patient was determined appropriate for hospice service" and signed by MD 1. During a telephone interview on 1/13/2023 at 11:23 am, Primary Care Physician (PCP 2) stated he was not notified Patient 12 and Patient 13 was placed in hospice care until December 2022. PCP 2 stated he was the primary physician for Patient 12 since 2015 and Patient 13 since 2013. PCP 2 stated these patients were developmentally disabled, doing good and were not terminally ill. PCP 2 stated Patient 12 was 37 years old and had diagnoses of schizophrenia and dysphagia and did not have heart disease. PCP 2 stated Patient 13 had seizures, high blood pressure and an old myocardial infarction (MI, also known as a heart attack, is a life-threatening condition that occurs when blood flow to the heart muscle is abruptly cut off, causing tissue damage). PCP 2 stated these patients were not eligible for hospice and would not refer these patients for hospice care. During a telephone interview on 1/13/2023 at 3:30 pm, MD 1 stated she has not seen any patients admitted to the hospice agency and the hospice staff is not keeping her in the loop regarding any of the patients. MD 1 stated she does not have access to the Hospice MD (an accessible and secure web-based application used to manage, access and update patient electronic health records) and has not signed any Certificates of Terminal Illness (CTI) or Interdisciplinary Group (IDG) meeting updates. MD 1 stated she was not aware who has been responsible for seeing the patients or signing the patients documents. A review of the hospice agencys policy titled, Certification of Terminal Illness, dated 11/2020, 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 patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on his/her review of the patient's medical record or, if applicable, examination of the patient. The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms. a. A review of Patients 3s Patient Information Sheet, indicated a SOC date of 5/13/22, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain) and included secondary diagnoses of hypertension, coronary artery stent (surgical procedure to open up blocked arteries), rheumatoid arthritis (chronic inflammatory disease affecting the joints), chest pain and muscle weakness. A review of Patient 3s CTI for the first 90- day period from 5/13/22-8/10/22, indicated a terminal illness of atherosclerotic heart disease of native coronary artery without angina pectoris. The CTI was signed by the HAs medical director (MD2) and did not indicate any communication between the HAs MD2 and Patient 3s primary care physician (PCP) to validate that Patent 3 had a life expectancy of six months or less, if terminal illness ran its normal course. During an interview on 1/6/23, at 1:29 p.m., Patient 3 stated that she is not terminally ill, just has heart disease. b. A review of Patient 4s Patient Information Sheet indicated a SOC date of 5/12/22, with primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Patient 4s secondary diagnoses include chronic atrial fibrillation (an irregular, rapid heart rate that can cause poor blood flow), hypertension, coronary artery stent and chest pain. A review of Patient 4s CTI for the first 90- day period from 5/12/22-8/9/22, indicated a terminal illness of atherosclerotic heart disease of native coronary artery without angina pectoris. The CTI was signed by the HAs medical director (MD3) and did not indicate any communication between the HAs MD3 and Patient 4s primary care physician (PCP) to validate that Patent 4 had a life expectancy of six months or less, if terminal illness ran its normal course. During an interview on 1/6/23, at 1:35 p.m., Patient 4 stated he was not terminally ill. During an interview on 1/13/23, at 11:38 p.m., Patient 3 and 4's primary physician 1 (PCP 1) stated he was not aware that Patients 3 and 4 were signed to hospice. He did not refer them. They should not be on Hospice. They do not have a terminal illness. PCP 1 stated Patient 3 and 4 are old and have multiple health problems, but they are stable.

Based on observation, interview, and record review, the hospice agency failed to ensure the medical director and/or physician designee conducted accurate recertifications of terminal illness for continued hospice care and services, for 10 of 13 sample patients (Patients 1, 2, 3, 4, 5, 9, 10, 12, 13, and 14) by failing to: Ensure that Patients 1, 2, 3, 4, 5, 9, 10, 12, 13, and 14s recertification has the physician's documentation of clinical information (including current history and physician's, laboratory and imaging data biopsy results, etc.), conducted a face-to-face assessment of patient and has 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 recertified 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 to lack and inappropriate care and services. --- a. A review of Patient 1s Patient Information Sheet, indicated a re-admit Start of Care date (SOC) of 10/15/22, with a primary diagnosis of end stage heart failure (when the heart can no longer pump blood throughout the body adequately. No secondary diagnoses were listed. A review of Patient 1s "Physician's Certification for Hospice Benefit " (CTI) for re-certification #5 dated 10/15/22-12/13/22 and certification #6 dated 12/14/22-2/11/23, indicated no RN Prognosis Summary and the Physician Narrative (face to face summary and certifying physician summary), were left blank, and did not have a Medical Director signature. b. A review of Patient 2s Patient Information Sheet, indicated a start of care (SOC) date of 8/1/22, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). Patient 2 had multiple secondary diagnoses with included essential primary hypertension (high blood pressure), chest pain and type 2 diabetes mellitus (DM-high levels of sugar in the blood, where over time causes damage to the heart, blood vessels, eyes, kidneys and nerves). A review of Patient 2s CTI for re-certification #2, dated 10/30/22-1/27/23, indicated no RN Prognosis Summary and the Physician Narrative (face to face summary and certifying physician summary), were left blank, and did not have a Medical Director signature. c. A review of Patients 3s Patient Information Sheet, indicated a SOC date of 5/13/22, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain). Other of Patient 3s diagnosis included hypertension, coronary artery stent (surgical procedure to open up blocked arteries), rheumatoid arthritis (chronic inflammatory disease affecting the joints), chest pain and muscle weakness. A review of Patient 3s CTI for re-certification #2, dated 8/11/22-11/8/22, did not have a Medical Director signature. Patient 3s CTI for re-certification #3, dated 11/9/22-1/7/23 and re-certification #4, dated 1/8/23-3/8/23, indicated no RN Prognosis Summary and the Physician Narrative (face to face summary and certifying physician summary), were left blank, and did not have a Medical Director signature. d. A review of Patient 4s Patient Information Sheet indicated a SOC date of 5/12/22, with primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Patient 4s secondary diagnoses include chronic atrial fibrillation (an irregular, rapid heart rate that can cause poor blood flow), hypertension, coronary artery stent and chest pain. Patient 4s CTI for re-certification #2, dated 8/10/22-11/7/22 and re-certification #3, dated 11/8/22-1/6/23, indicated no RN Prognosis Summary and the Physician Narrative (face to face summary and certifying physician summary), were left blank, and did not have a Medical Director signature. e. A review of Patient 5s Patient Information Sheet indicated a SOC date of 12/1/21, with primary diagnosis of hypertensive heart disease with heart failure, with secondary diagnosis of DM. Patient 5s CTI for re-certification #2, dated 8/10/22-11/7/22 and re-certification #5, dated 9/27/22-1/25/22, indicated no RN Prognosis Summary and the Physician Narrative (face to face summary and certifying physician summary), were left blank, and did not have a Medical Director signature. f. A review of Patient 9's Patient Profile indicated a Start of Care (SOC) on 12/19/2021 with a primary diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (condition when heart does not pump enough blood to the body). A review of Patient 9s Certificate of Terminal Illness (CTI) #3, Re-Certification Statement Next 60-day period, 6/17/2022 to 8/15/2022, indicated the Physician Narrative: Face to Face Summary was blank. The CTI did not have a Medical Director signature. A review of Patient 9s CTI #4 for certification period 8/16/2022 to 10/14/2022, CTI #5 for certification period 10/15/2022 to 12/13/2022, and CTI #6 for certification period 12/14/2022 to 2/11/2023, indicated no RN Prognosis Summary and the Physician Narrative (face to face summary and certifying physician summary), were left blank, and did not have a Medical Director signature. g. A review of Patient 10s Patient Profile indicated a Start of Care (SOC) on 5/1/2022 with a primary diagnosis of unspecified diastolic congestive heart failure (condition in which your heart's main pumping chamber (left ventricle) becomes stiff and unable to fill properly). A review of Patient 10s CTI #3 for certification period 10/28/2022 to 12/26/2022 indicated there was no RN Prognosis Summary or Physician Narrative (face to face summary or certifying Physician summary). They were left blank and did not have a Medical Director signature. h. A review of Patient 12s Patient Profile indicated a Start of Care (SOC) on 6/27/2022 with a primary diagnosis of heart disease (disease that can affect heart muscle, valves and blood vessels). A review of Patient 12s CTI #2 for certification period 9/25/2022 to 12/23/2022 indicated no documented evidence of basis for certification (no indication of medical history, record and patient status, team assessment or face to face encounter) or an RN Prognosis Summary. The CTI #2 indicated in the certifying physician summary that ";per IDT discussion and recommendation, the patient remains appropriate for hospice at this time. Continue to provide comfort measures" and was signed by MD 1. A review of Patient 12s CTI #3 for certification period 12/24/2022 to 2/21/2023 indicated no documented evidence in the RN prognosis summary or Physician Narrative (face to face summary and certifying physician summary) and was not signed by the hospice medical director. i. A review of Patient 13s Patient Profile indicated a Start of Care (SOC) on 6/27/2022 with a primary diagnosis of seizures (a sudden, uncontrolled electrical disturbance in the brain). A review of Patient 13s CTI #2 for certification period 9/25/2022 to 12/23/2022 indicated there was no documented evidence of basis for certification (no indication of medical history, record and patient status, team assessment or face to face encounter),or an RN Prognosis Summary or Physician narrative (face to face summary or certifying physician summary). The CTI #2 was not signed by the hospice medical director. A review of Patient 13s CTI #3 for certification period 12/24/2022 to 2/21/2023 indicated there was no documented evidence in the RN prognosis summary or Physician Narrative (face to face summary and certifying physician summary and the certification was not signed by the hospice medical director. j. A review of Patient 14s Patient Profile indicated a Start of Care (SOC) on 4/7/2022 with a primary diagnosis of atherosclerosis heart disease of native coronary artery (hardening of the heart arteries) without angina pectoris (chest pain). The Patient Profile indicated Patient 14 was a re-admit and starting on certification #3. A review of Patient 14s CTI #4 for certification period 6/6/2022 to 8/4/2022, CTI #5 for certification period 8/5/2022 to 10/3/2022, CTI #6 for certification period 10/4/2022 to 12/2/2022, and CTI#7 for certification period 12/3/2022 to 1/31/2023 indicated there was no documented evidence of the basis for certification (no indication of medical history, record and patient status or team assessment), and no RN Prognosis Summary or Physician narrative (face to face summary or certifying physician summary). The CTI's were not signed by the hospice medical director. During a telephone interview on 1/13/2023 at 3:30 pm, MD 1 stated she has not seen any patients admitted to the hospice agency and the hospice staff is not keeping her in the loop regarding any of the patients. MD 1 stated she does not have access to the Hospice MD (an accessible and secure web-based application used to manage, access and update patient electronic health records) and has not signed any Certificates of Terminal Illness (CTI) or Interdisciplinary Group (IDG) meeting updates. MD 1 stated she was not aware who has been responsible for seeing the patients or signing the patients documents. A review of the hospice agencys policy titled Certification of Terminal Illness, dated 11/2020, 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 that 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 patient's medical record or, if applicable, examination of the patient. The policy indicated that the hospice physician or nurse practitioner must have a face-to-face encounter with the patient within the 30 days prior to the third benefit period recertification and within 30 days prior to each subsequent recertification.

Based on interview and record review the hospice agency (HA) failed to maintain patient clinical records in accordance to federal guidelines as evidenced by the following. The HA did not retain the paper charts for two of two sampled discharged patients (Patient 6 and 7). (refer to L681). Discharge summaries for patients 6 and 7 were incomplete (refer to 684) Entries in Patient 2,3,4, and 5's electronic medical record were not authentic (Refer L679) 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 are provided to the patients certified to receive hospice services. --- .

Based on record review and interview the Hospice Agency (HA) failed to ensure documentation in four of eleven sampled patients (Patient 2, 3, 4 and 6) was accurate and authentic. Nursing notes entered by a unknow staff member for Patients 2, 3, and 4. Patients 2 and 5's Physician's Certification for Hospice Benefit signed by unknown staff member. This deficient practice resulted in the failure to document accurately and ensure authenticity of the patients' clinical records. --- 1.a. A review of Patient 2s "Physician's Certification for Hospice Benefit," (CTI) for the first 90- day period from 8/1/22-10/29/22, indicated a terminal diagnosis of hypertensive heart disease with heart failure. A review of Patient 2s electronic medical record (EMR) showed LVN Visit Notes dated 10/6/22,10/13/22,1 0/27/22 and 11/10/22. The note indicated that it was created by Registered Nurse 1 (RN 1), staff assigned was Licensed Vocational Nurse 1 (LVN 1). RN 1 signed the note and it says ";to close note on behalf of staff assigned". 1.b. A review of Patients 3s Patient Information Sheet, indicated a SOC date of 5/13/22, with a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain). Other of Patient 3s diagnosis included hypertension, coronary artery stent (surgical procedure to open up blocked arteries), rheumatoid arthritis (chronic inflammatory disease affecting the joints), chest pain and muscle weakness. A review of Patient 3s electronic medical record (EMR) showed LVN Visit Notes dated 9/17/22 and 9/26/22. The note indicated that it was created by Registered Nurse 1 (RN 1), staff assigned was Licensed Vocational Nurse 1 (LVN 1). RN 1 signed the note and it says ";to close note on behalf of staff assigned". 1.c. A review of Patient 4s Patient Information Sheet indicated a SOC date of 5/12/22, with primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris. Patient 4s secondary diagnoses include chronic atrial fibrillation (an irregular, rapid heart rate that can cause poor blood flow), hypertension, coronary artery stent and chest pain. A review of Patient 4s electronic medical record (EMR) showed LVN Visit Notes dated 10/21/22, 10/28/22,11/8/22, 11/17/22, 11/21/22. The note indicated that it was created by Registered Nurse 1 (RN 1), staff assigned was Licensed Vocational Nurse 1 (LVN 1). RN 1 signed the note and it says ";to close note on behalf of staff assigned". During an interview on 1/13/23, at 2:00pm, Registered Nurse 1 (RN 1) stated that she does not do any documentation in the electronic medical record (EMR). RN 1 stated that she does her charting on a paper form, then the office staff transfers it to the EMR. RN 1 could not remember the name of the office staff. RN 1 stated that she does not know how to create a note in the EMR. RN 1 stated that she did not create any notes for LVN 1, and she does not know who did. During an interview on 1/13/23, at 2:15pm, the Owner stated that GC LVN 1 had trouble accessing the EMR, that is why notes were created under RN 1s. During an interview on 1/13/23, at 3:50pm, the Owner stated that LVN 1 is an employee, but is currently not seeing patients because he has not provided required document to update employee file. Owner stated that the last time s\he had patients was sometime last year. During an interview on 1/12/23 at 11:05am, LVN 1 stated that a long time ago he went to apply for the job position, but he never finished the application, and he never gave them his credentials. LVN 1 stated that he never worked with any patients and never worked in the office. LVN 1 stated that he does not know why he notes in system and that he never documented any notes. 2.a. A review of Patient 2s Patient Information Sheet, indicated a start of care (SOC) date of 8/1/22, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). Patient 2 had multiple secondary diagnoses with included essential primary hypertension (high blood pressure), chest pain and type 2 diabetes mellitus (DM-high levels of sugar in the blood, where over time causes damage to the heart, blood vessels, eyes, kidneys and nerves). A review of Patient 2s "Physician's Certification for Hospice Benefit," (CTI) for the first 90- day period from 8/1/22-10/29/22, indicated a terminal diagnosis of hypertensive heart disease with heart failure. The CTI was signed by the HAs medical director 1 (MD 1) 2b. A review of Patient 5s Patient Information Sheet indicated a SOC date of 12/1/21, with primary diagnosis of hypertensive heart disease with heart failure, with secondary diagnosis of DM. A review of Patient 5s CTI for re-certification # 3, dated 5/30/22-7/28/22, and #4, dated 7/29/22-9/26/22, indicated a terminal illness of hypertensive heart disease with heart failure. The CTI had MD 3s name listed as medical director/physician designee, but it was signed by MD 1 verifying the CTI. During a telephone interview on 1/13/23, at 3:30pm, MD 1 stated that she has not been signing any documents because she does not know what is going on with the HA. MD 1 stated that she does not have access to the electronic charting system, she has not done any home visits with any patients. MD 1 stated she does not know who has been responsible for seeing the patients and signing documents. A review of the HA's policy titled " Entries into the Clinical Record", dated 11/2020, indicated that hospice personnel providing direct patient care and supervisory functions have the authority to make entries into the clinical record...Personnel authorized to use a computer to authenticate documentation will sign a computer confidentiality statement, verifying that no one else will be allowed to use their computer password. Each staff member will be responsible for the security of his/her computer password.

Based on observation, interview and record review, the hospice agency (HA) failed to retain the paper chart for two of two sampled residents for six years after discharge in accordance with its policy and procedure (Patient 6 and 7). This deficient practice resulted in the failure to safeguard and retain the patients' clinical records. --- a. A review of Patient 6s Patient Information Sheet indicated a SOC date of 5/18/22 and an end of service date (EOC-discharge date) of 8/4/22, with a primary diagnosis of hypertensive chronic kidney disease (condition caused by high blood pressure that leads to the kidneys no longer being able to filter waste from the blood). Patient 6s secondary diagnoses included plural effusion (build up of fluid between the tissues that line the lungs and chest causes shortness of breath, cough, and pain), and unstable gait and frequent falls. A review of Patient 6s discharge summary indicated an EOC date of 8/4/22, and the reason for discharge was hospitalization. b. A review of Patient 7s Patient Information Sheet indicated an SOC date of 9/25/21 and an EOC date of 10/31/22. Patient 7 had a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain) and no secondary diagnoses. A review of Patient 7's discharge summary indicated an EOC date of 10/31/22, and the reason for discharge was prognosis extended. On 1/13/23, at 2:33pm, Patient 6 and 7s paper chart was requested, but RN1 and the Owner were not able to find it. The owner stated she did not know where the chart was. It should be kept in the file cabinet. A review of the HA's policy titled "Safeguarding/retrieval of Clinical Records", dated 11/2020, did not indicate a time frame for retaining patient records.

Based on interview and record review, the hospice agency (HA), failed to complete discharge summaries for two of two sampled patients (Patients 6 and 7). This deficient practice resulted in the status of the patients' health condition at discharge was unknown. --- a. A review of Patient 6s Patient Information Sheet indicated a SOC date of 5/18/22 and an end of service date (EOC-discharge date) of 8/4/22, with a primary diagnosis of hypertensive chronic kidney disease (condition caused by high blood pressure that leads to the kidneys no longer being able to filter waste from the blood). Patient 6s secondary diagnoses included plural effusion (build up of fluid between the tissues that line the lungs and chest causes shortness of breath, cough, and pain), unstable gait and frequent falls. A review of Patient 6s discharge summary indicated an EOC date of 8/4/22, reason for discharge was hospitalization. The nurses narrative note stated that the patient sought aggressive treatment. No other information was given. A review of Patient 6s electronic medical record (EMR) did not have any Interdisciplinary Group (IDG) notes related to the discharge nor any nursing visit notes. A review of Patient 6s Discharge plan, dated 10/31/22, indicated the reason for discharge was prognosis extended. There were no nursing comments. b. A review of Patient 7s Patient Information Sheet indicated an SOC date of 9/25/21 and an EOC date of 10/31/22. Patient 7s had a primary diagnosis of atherosclerotic heart disease of native coronary artery (a buildup of cholesterol (fat) in the walls of the arteries causing obstruction of blood flow) without angina pectoris (chest pain) and no secondary diagnoses. A review of Patient 7s discharge summary indicated an EOC date of 10/31/22, reason for discharge was prognosis extended. The nurses narrative note was empty. A review of Patient 7s electronic medical record (EMR) did not have any Interdisciplinary Group (IDG) notes related to the discharge. During an interview on 1/13/23, at 2:25pm, RN 1 stated that that patients should have a completed discharge summary and nursing notes so you can see the patients discharge assessment and know why they are being discharged. A review of the HAs policy titled ";Discharge From Hospice Program, dated 11/2020, indicated that 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: A. Reason for discharge B. Physical and psychosocial status at time of transfer or discharge, including specific medical, psychosocial, or other problems requiring interventions or follow-up. C. Summary of the care provided and progress toward achieving goals, including both positive and adverse patient responses to treatment or services. D. The date of discharge, which is the date of the last visit made.

Based on interview and record review, the hospice agency (HA), failed to ensure background checks were done on all employees. This deficient practice had the potential to allow someone with a criminal background to work, that could lead to harm of patients. --- a. During an interview on 1/6/23, at 12:57pm, the Owner stated that Licensed Vocational Nurse 1 (LVN 1) is an active employee. On 1/9/23, Licensed Vocational Nurse 1 (LVN 1) employee file was reviewed and was incomplete. There was no LVN credentials, no background check. No resume, and onboarding paperwork was not completed. During an interview on 1/9/23, at 12:26pm, the Owner stated that LVN 1 took his employee file home and never returned it with updated documents. That is why the file is not updated. During an interview on 1/12/23 at 11:05am, LVN 1 stated that a long time ago he went to apply for the job position, but he never finished the application and he never gave them his credentials. LVN 1 stated that he never worked with any patients and never worked in the office. b. During an interview on 1/6/23, at 12:57pm, the Owner stated that Registered Nurse 2 (RN 2) is an active employee, but is currently out sick. On 1/9/23, RN 2s employee file was requested, but the owner was unable to find file. Stated she does not know where office staff put it. During an interview on 1/6/23, at 12:42 pm, RN 2 stated that he fill out an application on 12/27/2022 for supervisor or field nurse. RN 2 stated that he has not seen any patients yet. c. During an interview on 1/6/23, at 12:57pm, the Owner stated that Spiritual Care (SC) is the main chaplain and an active employee. The Owner stated that she was still getting his employee filed together. A review of SCs employee File showed that SC did not fill out an application for employment, but he did have resume attached. There was no background check. Date of hire was 9/1/20. During a telephone interview on 1/5/2022, at 4:15 pm, the SC stated he was not the chaplain for the HA, had never worked with the Hospice agency, and was unaware on how the HA had his information. The SC stated he worked for multiple hospice agencies, but this was not one of them. On 1/6/23 at 1:15pm, the Owner stated that HR or the administrator is responsible for making sure that employee files are complete and up to date. Employee files should have resumes. Should be updated so everyone can work efficient, and no delays for them when they go visit patients and background checks should be done for all employees. A review of the HAs policy titled "; Selection/Hiring of Personnel", dated 11/2020, indicated that a criminal background check will be obtained for positions required by law, regulation or organizational policy.