Every finding on record at Blessing Hospice Care, Inc

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of the Patient was met as follows: 1. The hospice agency failed to ensure the patient's eligibility for hospice services related to the palliation (relief of symptoms and suffering caused by life threatening diseases) and management of the terminal illness and related conditions were accurately assessed, for three of 14 sampled patients (Patient 8, Patient 12, and Patient 14). (Refer to L524) 2. The hospice agency failed to provide initial bereavement assessment for two of 14 sampled patients (Patient 11 and Patient 12). (Refer to L531) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on observation, interview, and record review, the Hospice Agency (HA) staff failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status, and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness for three of 14 sampled patients (Patient 8, Patient 12, and Patient 14). This deficient practice resulted in the hospice agency certifying patients who did not meet the criteria required to receive the hospice benefits and service management of terminal illness that could affect their quality of life. --- Findings: a. During a record review of Patient 8s admission record indicated a start of care (SOC) date of 11/30/2023 with a terminal diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in the body, called aorta). The admission record also indicated Patient 8s referring/attending physician was Physician 2. During a review of Patient 8's Comprehensive Nursing 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), dated 11/30/2023, indicated Patient 8 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related (anything that's connected or related to the heart) pain, had normal respirations (breathing), had mild dyspnea (difficult or labored breathing), was dependent on walker or cane, and required moderate assistance with ambulation, toileting, transfer and feeding, and maximum assistance with dressing and bathing. The Comprehensive Nursing Assessment further indicated Patient 8 was on NYHA Class IV level for heart failure (New York Heart Association Class IV: Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). During a review of Patient 8's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the first benefit period from 11/30/2023 to 2/27/2024, indicated Patient 8's primary terminal diagnoses was atherosclerosis of aorta. The Medical Director (Physician 1) indicated Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence that hospice's Medical Director communicated with the patients primary physician to certify Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 8s terminal illness diagnosis. During a review of Patient 8s LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) Hospice Eligibility Determination form for Heart Disease, dated 11/30/2023, indicated Patient 8 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 8 had declined surgical procedures. Section 2 was marked "yes" that Patient 8s heart disease met the criteria for NYHA Class IV level. During a review of Patient 8's clinical record indicated there was no documented evidence that Patient 8 had declined any surgical procedures. There was no documentation Patient 8 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. On 2/14/2024 at 1:53 p.m., during a telephone interview with Patient 8, Patient 8 stated no doctor or nurses told him that he had six months or less to live. Patient 8 stated he was not dying, had four surgeries already and had not declined any surgical procedures, has been walking around his neighborhood without any assistance, and been fully independent with ADLs (or activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating). Patient 8 further stated Physician 2 was not his attending physician, does not know who she was and has not met, talked and/or discussed his medical history with her. On 2/15/2024 at 1:45 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated he was not able to find documented evidence that Patient 8 had declined surgical procedures nor any documentation that prior to admission to hospice care, Patient 8 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. DPCS stated Patient 8 was referred to the HA by Physician 2. DPCS further stated Physician 2 was a mobile physician contracted by the HA. b. During a review of Patient 12's admission record indicated a start of care date of 12/29/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), unspecified. The admission record also indicated Patient 12s referring/attending physician was Physician 2. During a review of Patient 12's Comprehensive Nursing Assessment, dated 12/29/2023, indicated Patient 12 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain, no edema, had normal respirations, regular pulse rate (heart rate), moderate dyspnea (shortness of breath) with speech, and ambulatory with assistance. During a review of Patient 12's "Physician Certification for Hospice Benefit" for the 2nd benefit period from 12/29/2023 to 3/27/2024, indicated Patient 12's terminal diagnoses was COPD. The Medical Director indicated Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence that hospice's Medical Director communicated with the patients primary physician to certify Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 12s terminal illness diagnosis. The ";RN (registered nurse) Assessment Narrative" section indicated Patient 12 met hospice LCD eligibility. During a review of Patient 12s LCD Hospice Eligibility Determination form for Pulmonary (pertaining to the lungs) Disease, dated 12/29/2023, indicated Patient 12 was eligible per LCD guidelines. The LCD form indicated in Section 1, a and b should be met. It was marked "yes" in Section 1a that Patient 12 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways) resulting in decreased functional capacity. Section 1b was marked "yes" that Patient 12 had respiratory failure and had an increasing physician home visits prior to hospice admission. During a review of Patient 12's clinical record indicated there was no documented evidence Patient 12 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, had respiratory failure or had an increasing physician home visits prior to hospice admission. During a joint home visit, on 2/15/2023 at 11:00 a.m. with the registered nurse (RN 1), Patient 12 was observed sitting on a wheelchair, awake, alert, and oriented, but hard of hearing. Patient 12 was on oxygen therapy via nasal canula (a medical device to provide supplemental oxygen therapy). The tip of the nasal canula was observed not in Patient 12s nostrils but sitting at the bridge of his nose. Patient 12 was observed having regular breathing, and not having shortness of breath. Patient 12 stated he does not know Physician 2. During a concurrent interview with RN 1, she stated she admitted and was the regular RN for Patient 12. RN 1 stated Patient 12 had shortness of breath only at times but not all the time and can be relieved with rest. RN 1 further stated Patient 12 never had a respiratory failure that requires the patient to be admitted in a hospital. On 2/15/2024 at 1:45 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated he was not able to find documented evidence that Patient 12 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, had respiratory failure or had an increasing physician home visits prior to hospice admission. DPCS stated Patient 12 was referred to the HA by Physician 2. c. During a review of Patient 14's admission record indicated a start of care date of 12/7/2023, with a terminal diagnosis of chronic obstructive pulmonary disease, unspecified. The admission record also indicated Patient 14s referring/attending physician was Physician 2. During a review of Patient 14's Comprehensive Nursing Assessment, dated 12/7/2023, indicated Patient 14 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain, had normal respirations, had moderate dyspnea with mild exertion, and needs maximum assistance with ambulation, toileting, transferring, dressing, and bathing, During a review of Patient 14's "Physician Certification for Hospice Benefit" for the 1st benefit period from 12/7/2023 to 3/5/2024, indicated Patient 14's terminal diagnoses was COPD. The Medical Director indicated Patient 14 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence that hospice's Medical Director communicated with the patients primary physician to certify Patient 14 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section was blank. There was no documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 14s terminal illness diagnosis. During a review of Patient 14s LCD Hospice Eligibility Determination form for Pulmonary Disease, dated 12/29/2023, indicated Patient 14 was eligible per LCD guidelines. The LCD form indicated in Section 1, a and b should be met. It was marked "yes" in Section 1a that Patient 14 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity. Section 1b was marked "yes" that Patient 14 had respiratory failure and had an increasing visits to ER (emergency room) and physician home visits prior to hospice admission. During a review of Patient 14's clinical record indicated there was no documented evidence that Patient 14 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, had respiratory failure or had an increasing ER visits and physician home visits prior to hospice admission. During a review of Patient 14's Communication Log, there was an entry dated 2/7/2024 at 12:23 pm., that indicated under the column "Event Type", it indicated "Check Status". Under the column "Comm (communication) Comments", it indicated, "Called patient to do status check, pt (patient) stated he's not dying, is doing well, no supplies or medication needed at this time." During a telephone interview on 2/14/2023 at 2:58 p.m. with Patient 14s family member (FM 1), FM 1 stated Patient 14 should not be in hospice care because he was independent, healthy, not having any shortness of breath, and doing fine. FM 1 stated Physician 2 is not the primary attending physician of Patient 14. On 2/15/2024 at 1:45 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated he was not able to find documented evidence Patient 14 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, had respiratory failure or had an increasing ER visits and physician home visits prior to hospice admission. During a review of the agencys policy and procedure titled "Admission Criteria and Process", revised November 2020, indicated the hospice agency will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of six months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). The organization will utilize referral information. If the request for service is not made by the patients physician, he/she will be consulted prior to the evaluation visit/initiation of services. During a review of the agencys policy and procedure titled ";Certification of Terminal Illness", revised November 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. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification.

Based on interview and record review, the hospice agency failed to provide initial bereavement assessment for two of 14 sampled patients (Patient 11 and Patient 12). This deficient practice placed the family at a potential risk for not receiving support and preparation for what to expect after the patients' death. --- Findings: a. During a review of Patient 11's demographics (refers to all of the non-clinical data about a patient, including: name, date of birth, address, phone number, email address, sex, race, etc.) indicated a start of care (SOC) date of 12/27/2023, with a terminal diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in the body, called aorta). During a review of Patient 11s POC (Plan of Care)/IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) form dated 1/10/2024, indicated the frequency of visits of skilled nurse (SN) to two visits per week and two (2) prn (pro re nata, which means ";as needed") visits, of social worker (MSW) to one visit for initial assessment, recertification, monthly, and as needed visits to provide psycho-social support for patient and family, and of spiritual counselor (SC) to one visit for initial, recertification, monthly, and as needed visits for spiritual assessment to provide spiritual care to patient and family. Hospice aide and volunteer services were offered but declined. During a review of Patient 11s clinical record indicated that there was no initial bereavement assessment conducted and/or completed. b. During a review of Patient 12's demographics indicated a start of care date of 12/29/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), unspecified. During a review of Patient 12s POC/IDG form dated 1/10/2024, indicated the frequency of visits of skilled nurse to two visits per week and three (3) prn (as needed) visits, of MSW for assessment/reassessment of patient/family psychosocial and emotional status, and of SC for assessment/reassessment of spiritual support status and provide counseling as needed. Hospice aide and volunteer services were offered but declined. During a review of Patient 12s clinical record indicated that there was no initial bereavement assessment conducted and/or completed. On 2/15/2024, at 1:45 p.m., during an interview with the Director of Patient Care Services (DPCS), DPCS stated that a bereavement assessment should be conducted on admission. The DPCS further stated that Patient 11 and Patient 12 did not have an initial bereavement assessment conducted on admission. During a review of the agency's policy and procedure titled "Bereavement Assessment," revised November 2020, indicated the hospice agency, will provide bereavement services for up to one year after the patients death to surviving family/caregiver members. The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of the patients death as part of the comprehensive assessment.

Based on interview, and record review, the hospice agency failed to ensure the IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary), Care Planning and Coordination of Services was met as followed: --- 3. The hospice agency nursing staff failed to coordinate care and ensure the IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) was notified and the notification was documented when ordered home visit service was missed for one out of 14 sampled patients (Patient 11). (Refer to L554) 4. The hospice agency failed to ensure home visit was conducted in accordance with the plan of care (POC) for one of 14 sampled patients (Patient 11). (Refer to L555) 1. The hospice agency (HA) failed to ensure care followed the written plan of care for one of 14 patients (Patient 3). The SN did not do a skin assessment on patient's right superior trochanter unstageable pressure ulcer (full thickness pressure injuries in which the base is obscured by slough or eschar) during a visit. This deficient practice placed the wound at risk for slow healing process. (Refer to L543). 2. The hospice agency failed to ensure physician orders were implemented for 1 of 14 sampled patients (Patient 3). This deficient practice placed the patient's open wound in delay of healing. (Refer to L549). The cumulative effects of these systemic practices resulted in the delay in the progress and delivery of the plan of care.

Based on interview and record review, the SN (skilled nurse ) failed to ensure care followed the written plan of care for one of 14 patients (Patient 3). The SN did not do a skin assessment on patient's right superior trochanter unstageable pressure ulcer (full thickness pressure injuries in which the base is obscured by slough or eschar) during a visit. This deficient practice placed the wound at risk for slow healing process. --- During a review of Patient 3's demographics (refers to all of the non-clinical data about a patient, including: name, date of birth, address, phone number, email address, sex, race, etc.) indicated a start of care (SOC) date of 2/7/2024, with a terminal diagnosis of senile degeneration of the brain (is the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age). During a review of Patient 3s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 2/7/2024, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus 2 prn (pro re nata, which means ";as needed") visits, of social worker (MSW) to one visit for initial assessment, re-certifications, monthly and as needed visits to provide psycho-social support for patient and family, and of spiritual counselor (SC) to one visit for initial, re-certifications, monthly and as needed visits for spiritual assessment to provide spiritual care to patient and family. Hospice aide and volunteer services were offered but declined. There was a wound care order dated 2/10/24,that was included in the plan of care for the unstageable pressure ulcer at right superior trochanter as follows: to cleanse with wound cleanser, pat dry, apply Medihoney (honey-based dressing , use to cover wounds) on the wound and cover with Silicone Bordered dressing three times a week. A review of Patient 3's LVN (license vocational nurse) Note dated 2/12/2024, indicated no documented evidence of a wound assessment was done on the patient's right superior trochanter. A review of Patient 3's Plan of Care dated 2/13/2024, for altered skin integrity related to wound at right hip indicated to assess the skin and pressure points for signs of breakdown every visit. On 2/14/2024, at 4 p.m., during an interview with the DPCS (director of patient care services), he stated there should be a skin assessment documentation that details of the wound such as drainage, color, odor or pain at site on every visit. A review of the agency's policy " Wound Management Policies", indicated that each patient's wounds must be documented on the wound assessment note and wound care plan, monitoring and evaluation documentation that details the history and evaluation of the wound. This documentation must include details such as the stage of wound healing, exudate (color, amount, odor), pain, wound measurements and include any underlying medical conditions.

Based on interview and record review, the hospice agency failed to ensure physician orders were implemented for one of 14 sampled patients (Patient 3). This deficient practice placed the patient's open wound in delay of healing. --- During a review of Patient 3's demographics (refers to all of the non-clinical data about a patient, including: name, date of birth, address, phone number, email address, sex, race, etc.) indicated a start of care (SOC) date of 2/7/2024, with a terminal diagnosis of senile degeneration of the brain (is the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age). During a review of Patient 3s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 2/7/2024, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus 2 prn (pro re nata, which means ";as needed") visits, of social worker (MSW) to one visit for initial assessment, re-certifications, monthly and as needed visits to provide psycho-social support for patient and family, and of spiritual counselor (SC) to one visit for initial, re-certifications, monthly and as needed visits for spiritual assessment to provide spiritual care to patient and family. Hospice aide and volunteer services were offered but declined. There was a wound care order dated 2/10/24,that was included in the plan of care for the unstageable pressure ulcer at right superior trochanter as follows: to cleanse with wound cleanser, pat dry, apply Medihoney (honey-based dressing, used to cover wounds) on the wound and cover with Silicone Bordered dressing three times a week. During a review of Patient 3's Initial Comprehensive Nursing Assessment dated 2/7/2024, indicated the patient had an unstageable wound at the right trochanter measuring three cm (centimeters) in length by five cm in width, with yellow slough and necrotic tissue present. However, there was no documented evidence the visiting nurse provided wound care during the visit. During a review of Patient 3's LVN (license vocational nurse) Note dated 2/12/2024, indicated no documented evidence of a wound treatment was done on the patient's right superior trochanter. A review of Patient 3's Plan of Care dated 2/13/2024, for altered skin integrity related to wound at right hip indicated to provide wound treatment as ordered and assess for effectiveness on every visits. On 2/14/2024, at 4 p.m., during an interview with the DPCS (director of patient care services), he stated the visiting nurse should be providing wound care as ordered on every visit. A review of the undated HA's policy and procedure titled, "Physician Orders Communications and Implementation", indicated the hospice agency will make follow-ups and monitoring if the order was carried out or implemented and collaborate with assigned discipline and patient/family representative regarding orders received and document.

Based on interview and record review, the hospice agency (HHA) failed to coordinate care and ensure the IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) was notified and the notification was documented when ordered home visit service was missed for one out of 14 sampled patients (Patient 11). This failure had the potential to result in patients end of life care needs not being met. --- Findings: During a review of Patient 11's demographics (refers to all of the non-clinical data about a patient, including: name, date of birth, address, phone number, email address, sex, race, etc.) indicated a start of care (SOC) date of 12/27/2023, with a terminal diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in your body, called your aorta). During a review of Patient 11s POC (Plan of Care) Summary form, indicated an order dated 12/28/2023, of the skilled nurse (SN) frequency of visits to two times per week plus 2 prn (pro re nata, which means ";as needed") visits for unanticipated symptoms management. . During a review of Patient 11s history of SN visits, it indicated Patient 11 was only visited once a week for the month of January 2024, and not two times a week as ordered. During a further review of Patient 11s clinical record indicated there was no documented evidence that the agencys nursing staff had notified or communicated with the IDG about the missed visit according to the agencys policy and procedure. On 2/15/2024, at 1:45 p.m., during an interview with the Director of Patient Care Services (DPCS), DPCS acknowledged the findings and stated patient care visit should be provided to patients in accordance with the plan of care. The DPCS stated for any missed visits, IDG should be notified promptly by the field nurses and notification should be documented in the patients electronic records per the agencys policies and procedures. During a review of the agencys policy and procedure titled, ";Missed Visits", revised November 2020, indicated missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a visit is missed and not rescheduled, the clinician will notify the IDG and clinical supervisor of the missed visit and reason for missed visit.

Based on interview and record review, the hospice agency failed to ensure home visit was conducted in accordance with the plan of care (POC) for one of 14 sampled patients (Patient 11). This failure had the potential to negatively affect the patients' physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. --- Findings: During a review of Patient 11's demographics (refers to all of the non-clinical data about a patient, including: name, date of birth, address, phone number, email address, sex, race, etc.) indicated a start of care (SOC) date of 12/27/2023, with a terminal diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in your body, called your aorta). During a review of Patient 11s POC (Plan of Care) Summary form, indicated an order dated 12/28/2023, of the skilled nurse (SN) frequency of visits to two times per week plus 2 prn (pro re nata, which means ";as needed") visits for unanticipated symptoms management. During a review of Patient 11s history of SN visits, it indicated Patient 11 was only visited once a week for the month of January 2024, and not two times a week as ordered. On 2/15/2024, at 1:45 p.m., during an interview with the Director of Patient Care Services (DPCS), DPCS acknowledged the findings and stated patient care visit should be provided to patients in accordance with the plan of care. During a review of the agency's policy and procedure titled, "The Plan of Care", revised November 2020, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Core Services was met as evidenced by: 1. The hospice agency failed to ensure medical social service was provided for two of 14 sampled patients (Patient 11 and Patient 12). (Refer to L594) 2. The hospice agency failed to ensure spiritual counseling service was provided and the spiritual counseling assessment was completed to meet patient's spiritual needs for two of 14 sampled patients (Patient 11,and Patient 12). (Refer to L598) These deficient practices resulted in the HA not providing the core services/care as required and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life.

Based on interview and record review, the hospice agency failed to ensure medical social services (services addressing social and emotional concerns related to the patient's illness and care and helping the patient access community) was provided and the psychosocial assessment was completed to meet patient's psychosocial needs for two of 14 sampled patients (Patient 11 and Patient 12). This failure had the potential for Patient 11 and Patient 12 to not receive information regarding supportive services for terminal illness, the dying process, and community resources. --- Findings: a. During a review of Patient 11's demographics (refers to all of the non-clinical data about a patient, including: name, date of birth, address, phone number, email address, sex, race, etc.) indicated a start of care (SOC) date of 12/27/2023, with a terminal diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in the body, called aorta). During a review of Patient 11s POC (Plan of Care)/IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) form dated 1/10/2024, indicated the frequency of visits of skilled nurse (SN) to two visits per week and two (2) prn (pro re nata, which means ";as needed") visits, of social worker (MSW) to one visit for initial assessment, recertification, monthly, and as needed visits to provide psycho-social support for patient and family, and of spiritual counselor (SC) to one visit for initial, recertification, monthly and as needed visits for spiritual assessment to provide spiritual care to patient and family. Hospice aide and volunteer services were offered but declined. During a review of Patient 11s clinical record did not indicate a documented psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was completed since the SOC. b. During a review of Patient 12's demographics indicated a start of care date of 12/29/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), unspecified. During a review of Patient 12s POC/IDG form dated 1/10/2024, indicated the frequency of visits of skilled nurse to two visits per week and three (3) prn (as needed) visits, of MSW for assessment/reassessment of patient/family psychosocial and emotional status, and of SC for assessment/reassessment of spiritual support status and provide counseling as needed. Hospice aide and volunteer services were offered but declined. During a review of Patient 12s clinical record did not indicate a documented psychosocial assessment was completed since the SOC. On 2/15/2024, at 1:45 p.m., during an interview with the Director of Patient Care Services (DPCS), DPCS stated if patients and/or patients family refused social worker services, the agencys MSW still needs to have an initial assessment in the patients clinical record of the services that was offered and the reason for refusal. DPCS acknowledged there was no MSW assessment completed for Patient 11 and Patient 12. During a review of the agency's policy and procedure titled "Psychosocial Assessment", revised November 2020, indicated a thorough psychosocial assessment will be initiated at the time of admission and continued throughout the course of care. The assessment will be completed and placed in the patients clinical record.

Based on interview and record review, the hospice agency failed to ensure spiritual counseling service was provided and the spiritual counseling assessment was completed to meet patient's spiritual needs for two of 14 sampled patients (Patient 11 and Patient 12). This deficient practice had the potential to result in patients not receiving spiritual and emotional support as necessary to cope with the terminal diagnosis and disease process. --- Findings a. During a review of Patient 11's demographics (refers to all of the non-clinical data about a patient, including: name, date of birth, address, phone number, email address, sex, race, etc.) indicated a start of care (SOC) date of 12/27/2023, with a terminal diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in the body, called aorta). During a review of Patient 11s POC (Plan of Care)/IDG (Interdisciplinary Group. a team responsible for the holistic care of the hospice beneficiary) form dated 1/10/2024, indicated the frequency of visits of skilled nurse (SN) to two visits per week and two (2) prn (pro re nata, which means ";as needed") visits, of social worker (MSW) to one visit for initial assessment, recertification, monthly, and as needed visits to provide psycho-social support for patient and family, and of spiritual counselor (SC) to one visit for initial, recertification, monthly, and as needed visits for spiritual assessment to provide spiritual care to patient and family. Hospice aide and volunteer services were offered but declined. During a review of Patient 11s clinical record did not indicate a documented spiritual assessment (an evaluation of an individual or family spiritual needs) was completed since the SOC. b. During a review of Patient 12's demographics indicated a start of care date of 12/29/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), unspecified. During a review of Patient 12s POC/IDG form dated 1/10/2024, indicated the frequency of visits of skilled nurse to two visits per week and three (3) prn (as needed) visits, of MSW for assessment/reassessment of patient/family psychosocial and emotional status, and of SC for assessment/reassessment of spiritual support status and provide counseling as needed. Hospice aide and volunteer services were offered but declined. During a review of Patient 12s clinical record did not indicate a documented spiritual assessment was completed since the SOC. On 2/15/2024 at 12:06 p.m., during a telephone interview with the agency's Spiritual counselor (SC1), SC 1 stated within five (5) days from the SOC, he needs to complete and then document in the patients electronic health record (EHR) a spiritual assessment. SC1 stated that even if the patient or the patients family decline spiritual counseling service, he still needs to complete an assessment in the patients EHR noting the refusal and the reason for such refusal. During a review of the agency's policy and procedure titled "Spiritual Assessment", revised November 2020, indicated a spiritual assessment will be completed for each patient/family by the Chaplain. The assessment will include, but not be limited to, evaluation of the following: 1. Coping with and adjusting to the patients terminal illness 2. Assessing bereavement needs 3. Religious and/or spiritual reactions to terminal illness.

Based on observation, interview, and record review, the Hospice Agency (HA,agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Medical Director was met as follows: --- 1. The HA failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation [specialized medical care for people living with a serious illness] of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for two out of 14 sampled patients (Patient 8 and Patient 14). (Refer to L667). 2. The HA failed to ensure the Medical Director and/or physician designee conducted a review and verified the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for one out of 14 sampled patients (Patient 12). (Refer to L668). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory (written rules or law) mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services.

Based on interview and record review, the hospice agency (HA) failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation [specialized medical care for people living with a serious illness] of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for two out of 14 sampled patients (Patient 8 and Patient 14). This deficient practice resulted in patients being admitted for hospice care with no documented evidence of patients written clinical information was being reviewed and evaluated by the Medical Director and/or physician designee to support their diagnoses of terminal illness. --- Findings: a. During a review of Patient 8s admission record indicated a start of care (SOC) date of 11/30/2023 with diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in your body, called your aorta). The admission record indicated Patient 8s referring/attending physician was Physician 2. During a review of Patient 8's Comprehensive Nursing 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), dated 11/30/2023, indicated Patient 8 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related (anything that's connected or related to the heart) pain, had normal respirations (breathing), had mild dyspnea (difficult or labored breathing), dependent on walker or cane, and required moderate assistance with ambulation, toileting, transfer and feeding, and maximum assistance with dressing, and bathing. The Comprehensive Nursing Assessment further indicated Patient 8 was on NYHA Class IV level for heart failure (New York Heart Association Class IV: Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). During a review of Patient 8's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the first benefit period from 11/30/2023 to 2/27/2024, indicated Patient 8's primary terminal diagnoses was atherosclerosis of aorta. The Medical Director (Physician 1) indicated Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the HA's Medical Director communicated with the patients primary physician to certify Patient 8 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 8s terminal illness diagnosis. During a review of Patient 8s LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) Hospice Eligibility Determination form for Heart Disease, dated 11/30/2023, indicated Patient 8 was eligible per LCD guidelines. The LCD form indicated Section 1 and Section 2 must be met. It was marked "yes" in Section 1 that Patient 8 had declined surgical procedures. Section 2 was marked "yes" that Patient 8s heart disease met the criteria for NYHA Class IV level. During a review of Patient 8's clinical record indicated there was no documented evidence Patient 8 had declined any surgical procedures. There was no documentation Patient 8 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. During a telephone interview on 2/14/2024 at 1:53 p.m., with Patient 8, Patient 8 stated no doctor or nurses told him that he had six months or less to live. Patient 8 stated he was not dying, had four surgeries already and had not declined any surgical procedures, has been walking around his neighborhood without any assistance, and been fully independent with ADLs (or activities of daily living, are activities related to personal care which includes bathing, grooming, dressing, toileting, and eating). Patient 8 stated, Physician 2 was not his attending physician, did not know who she was and has not met, talked and/or discussed his medical history with her. During a concurrent interview and record review on 2/15/2024 at 1:45 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated he was not able to find documented evidence Patient 8 had declined surgical procedures nor any documentation that prior to admission to hospice care, Patient 8 was on complete rest, confined to bed or chair, or any physical activity brings on discomfort and symptom at rest. DPCS stated Patient 8 was referred to the HA by Physician 2. DPCS further stated Physician 2 was a mobile physician contracted by the HA. b. During a review of Patient 14's admission record indicated a start of care date of 12/7/2023, with a terminal diagnosis of chronic obstructive pulmonary disease, unspecified. The admission record also indicated Patient 14s referring/attending physician was Physician 2. During a review of Patient 14's Comprehensive Nursing Assessment, dated 12/7/2023, indicated Patient 14 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain, had normal respirations, had moderate dyspnea with mild exertion, and needs maximum assistance with ambulation, toileting, transferring, dressing, and bathing, During a review of Patient 14's "Physician Certification for Hospice Benefit" for the 1st benefit period from 12/7/2023 to 3/5/2024, indicated Patient 14's terminal diagnoses was COPD. The Medical Director indicated Patient 14 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 14 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section was blank. There was no documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 14s terminal illness diagnosis. During a review of Patient 14s LCD Hospice Eligibility Determination form for Pulmonary Disease, dated 12/29/2023, indicated Patient 14 was eligible per LCD guidelines. The LCD form indicated in Section 1, a and b should be met. It was marked "yes" in Section 1a that Patient 14 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity. Section 1b was marked "yes" that Patient 14 had respiratory failure and had an increasing visits to ER (emergency room) and physician home visits prior to hospice admission. During a review of Patient 14's clinical record indicated there was no documented evidence Patient 14 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, had respiratory failure or had an increasing ER visits and physician home visits prior to hospice admission. During a telephone interview on 2/14/2023 at 2:58 p.m. with Patient 14s family member (FM 1), FM 1 stated Patient 14 should not be in hospice care because Patient 14 was independent, healthy, not having any shortness of breath, and doing fine. FM 1 stated Physician 2 was not the primary attending physician of Patient 14. During a telephone interview on 2/15/2024 at 12:55 p.m. with the HA's Medical Director (Physician 1), Physician 1 stated he was not the attending physician, did not know who the attending physician was, nor have discussed or spoken with them for Patient 8 and Patient 14. Physician 1 stated he determined Patient 8 and Patient 14 were eligible for hospice care through the nurse visit, their assessment and discussion with the hospice staff. When asked if prior to hospice admission he reviewed patient's hospital records, attending physician's progress notes, laboratory and diagnostic test results to certify patients had terminal illness, Physician 1 stated , "No, I don't carry those with me." During a concurrent interview and record review on 2/15/2024 at 1:45 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated he was not able to find documented evidence Patient 14 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, had respiratory failure or had an increasing ER visits and physician home visits prior to hospice admission. During a review of the agencys policy and procedure titled ";Certification of Terminal Illness", revised November 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. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. During a review of the agencys policy and procedure titled ";Physician Services-Medical Director Role", revised November 2020, indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care.

Based on observation, interview, and record review, the HA failed for the Medical Director or physician designee, that hospice patients' clinical information was reviewed to obtain justifications to recertify for continued hospice care and services for one out of 14 sampled patients (Patient 12). This deficient practice resulted in Patient 12, to be re-certified for hospice care lacking verification of the clinical information to continue provision of hospice care which can affect their quality of life and well-being. --- Findings: During a review of Patient 12's admission record indicated a start of care (SOC) date of 12/29/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe), unspecified. The admission record also indicated Patient 12s referring/attending physician was Physician 2. During a review of Patient 12's Comprehensive Nursing 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), dated 12/29/2023, indicated Patient 12 was awake, alert, oriented x 3 (to person, place, and time), had no cardiac-related pain, no edema (swelling caused by too much fluid trapped in the body's tissues), had normal respirations (breathing), regular pulse rate (heart rate), moderate dyspnea (shortness of breath) with speech, and ambulatory with assistance. During a review of Patient 12's "Physician Certification for Hospice Benefit" (Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the 2nd benefit period from 12/29/2023 to 3/27/2024, indicated Patient 12's terminal diagnoses was COPD. The Medical Director indicated Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section did not indicate any documented evidence and supporting narrative from the Medical Director that included laboratory test results, imaging data, history and physical, and biopsy results to support Patient 12s terminal illness diagnosis. The ";RN (registered nurse) Assessment Narrative" section indicated Patient 12 met hospice LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) eligibility. During a review of Patient 12s LCD Hospice Eligibility Determination form for Pulmonary (pertaining to the lungs) Disease, dated 12/29/2023, indicated Patient 12 was eligible per LCD guidelines. The LCD form indicated in Section 1, a and b should be met. It was marked "yes" in Section 1a that Patient 12 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways) resulting in decreased functional capacity. Section 1b was marked "yes" that Patient 12 had respiratory failure and had an increasing physician home visits prior to hospice admission. During a review of Patient 12's clinical record indicated there was no documented evidence Patient 12 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, had respiratory failure or had an increasing physician home visits prior to hospice admission. During a joint home visit, on 2/15/2023 at 11:00 a.m. with the registered nurse (RN 1), Patient 12 was observed sitting on a wheelchair, awake, alert, and oriented, but hard of hearing. Patient 12 was on oxygen therapy via nasal cannula (a medical device to provide supplemental oxygen therapy). The tip of the nasal cannula was observed not in Patient 12s nostrils but sitting at the bridge of his nose. Patient 12 was observed having regular breathing, and not having shortness of breath. Patient 12 stated he does not know Physician 2. During a concurrent interview with RN 1, she stated she admitted and was the regular RN for Patient 12. RN 1 stated Patient 12 had shortness of breath only at times but not all the time and can be relieved with rest. RN 1 further stated Patient 12 never had a respiratory failure that requires the patient to be admitted in a hospital. On 2/15/2024 at 12:55 p.m., during a telephone interview with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician, did not know who the attending physician was nor have discussed or spoken with them for Patient 12. Physician 1 stated he determined patient's were eligible for hospice care through the nurse visit, their assessment and discussion with the hospice staff. When asked if prior to hospice admission he reviewed patient's hospital records, attending physician's progress notes, laboratory and diagnostic test results to certify patients had terminal illness, Physician 1 stated , "No, I don't carry those with me." On 2/15/2024 at 1:45 p.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated he was not able to find documented evidence Patient 12 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, had respiratory failure or had an increasing physician home visits prior to hospice admission. DPCS stated Patient 12 was referred to the HA by Physician 2. DPCS further stated Physician 2 was a mobile physician contracted by the HA. During a review of the HA's policy and procedure ";Certification of Terminal Illness", revised November 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. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. During a review of the HA's policy and procedure ";Physician Services-Medical Director Role", revised November 2020, indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care.

Based on observation, interview, and record review, the hospice agency (HA) failed to provide the patient's their right to be informed of the accurate information for filing a complaint for one of 14 sample patients (Patient 4). The deficient practice resulted in the patient/caregiver lacked the knowledge on how to lodge their complaints leading in the delay to investigate and resolve the complaint that could impact the patient's quality of care. --- Findings: A review of Patient 4's clinical record indicated a start of care date (SOC) of 09/12/2022, with diagnosis of senile degeneration of the brain (senile degeneration of the brain). A review of Patient 4s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/26/2023, indicated the frequency of visits of the skilled nurse (SN) was one visit per week plus 3 PRN (pro re nata, which means ";as needed") visits. On 8/09/2023, at 12:35 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 1) was conducted at Patient 4s residence at the Assisted Living Facility (ALF). Patient 4 was observed lying in a hospital bed asleep. The Medication Technician from ALF was present at bedside during the home visit. A review of the hospice agency folder located at the ALF indicated the hospice agency did not provide information on how to file the patient's complaint or concern to the Department of Public Health (DPH) if needed. A review of the hospice agencys sample admission packet also indicated the agency did not provide information regarding how to file a complaint or concern to the Department of Public Health (DPH) if needed. During a concurrent record review, and interview with the Director of Patient Care Services (DPCS), on 08/11/2023, at 4:36 p.m., he stated that the phone number and address for the Department of Public Health should be included in the admission packet for patients to file a complaint. A review of the agencys ";Patients Right and Responsibilities" undated, indicated that the patient bill of rights is designated to recognize, protect, and promote the rights of each patient to be treated with dignity and respect.

Based on observation, interview and record review, the hospice agency (HA) failed to maintain an accurate, current medication profile for two of 14 sampled patients (Patient 4 and Patient 8). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions that could affect the health and safety of the patients. --- Findings: b. A review of Patient 8's clinical record indicated he was admitted to the hospice agency on 3/20/2023, with a terminal diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in your body, called your aorta). A review of Patient 8s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/26/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus 2 prn (pro re nata, which means ";as needed") visits to assess and monitor effectiveness of the current and new medications or treatments, and to instruct the patient and/or patient caregiver (pcg) regarding new medication or treatment orders and side effects. On 8/09/2023, at 10:30 a.m., a joint home visit was conducted at Patient 8's residence, with the Director of Patient Care Services (DPCS). Patient 8 was observed lying in a hospital bed, awake, alert but confused. The patients caregiver (Pcg 1) was present at bedside. On 8/09/2023, at 10:50 a.m., during a review of Patient 8s current medication, Robitussin DM (a cough medicine) cough liquid bottle was not found. However, the patients current medication profile provided by the HA indicated patient was taking the medication. During an interview with Pcg 1, she stated Patient 8 was prescribed the cough medicine only for 10 days several months before and was not taking it currently. On 8/10/2023 at 11:30 a.m., during an interview with the DPCS, the DPCS stated nursing staff need to review patients current medication on every visit and update the medication profile in the patients clinical record. A review of the hospice agencys policy and procedure titled, ";Medication Profile", revised November 2022, indicated patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. a. A review of Patient 4's clinical record indicated a start of care date (SOC) of 09/12/2022, with diagnosis of senile degeneration of the brain (senile degeneration of the brain). A review of Patient 4s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/26/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus 3 prn (pro re nata, which means ";as needed") visits. On 8/09/2023, at 12:35 p.m., a joint home visit with the Licensed Vocational Nurse (LVN 1) was conducted at Patient 4s residence. Patient 8 was observed lying in a hospital bed asleep. Medication Technician at the Assisted Living Facility (ALF) present at bedside. A review of Patient 4s Medication Profile provided by the hospice agency , indicated that patient had an order for Robitussin 100 mg (milligram – unit of measurement) per 5 ml (milliliter – unit of measurement) and antacid 20 mg per 5 ml. A review of Patient 4s current medication indicated the patient takes mucus and chest congestion 200 mg per 5 ml and no longer takes Robitussin. Further review of Patient 4s current medication also indicated patients antacid medication was discontinued. During an interview with the Medication Technician on 08/09/2023 at 1:05 p.m., she stated that Patient 4 had a different cough medicine and that the antacid medication was discontinued.

Based on interview, and record review, the hospice agency failed to conduct the initial bereavement assessments for two of 14 sample patients (Patient 1 and 5). This deficient practice has the potential to result in the patient/family's identified needs and resources will not be met that could impact their ability to cope with the patient's death. --- Findings: a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 07/10/2023 and an end of care date (EOC) of 07/29/2023, with diagnosis of malignant neoplasm of colon (cancer of the colon). A review of Patient 1s POC/IDG form dated 7/26/2023, indicated the frequency of visits of skilled nurse (SN) daily visits for symptom management times three days. A review of Patient 1s clinical record indicated there was no documented evidence of an initial bereavement assessment was conducted. b. A review of Patient 5's clinical record indicated a start of care date (SOC) of 05/16/2023, with diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in your body, called your aorta). A review of Patient 5s POC/IDG form dated 07/26/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus three prn visits. A review of Patient 5s clinical record indicated there was no initial bereavement assessment conducted. During a concurrent record review and interview with the Director of Patient Care Services (DPCS), on 08/11/2023, at 3:20 p.m., he stated that initial bereavement assessment should be done within four days of admission. DPCS further stated no initial bereavement assessment for Patient 1 and Patient 5 were conducted. A review of the agencys policy and procedure titled ";Bereavement Services," dated 11/2020, indicated that the purpose of the policy and procedure is to ensure that appropriate and coordinated bereavement services are provided to families/caregivers. The policy and procedure further indicated that a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services were met as follows: 1. The hospice agency failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were held by all the members of IDG to discuss the patients comprehensive assessment (an assessment conducted by a Registered Nurse and is based on a physical assessment of the individual and a review of the individual's medical records, including physician notes, lab results and all other pertinent clinical records) and other ongoing assessments and care planning process for 11 out of 14 sampled patients, (Patients 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13). (Refer to L541). 2. The hospice agency failed to ensure the frequency of Spiritual Counsellor (a person who meets the psychosocial and spiritual needs of a patient) visits necessary to meet the spiritual needs of one of 14 sampled patients, (Patient 8) was indicated in the hospice plan of care (the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers). This deficient practice had the potential that patient's spiritual needs will not be met that could negatively affect the patients quality of life. (Refer to L547). 3. The hospice agency failed to follow its policies and procedures by failing to: Ensure the primary care physician verified the patients hospice (patients who are terminally ill and has six months or less to live) eligibility for hospice care and services for four of 14 sampled patients, (Patient 1, 5, 6 and 7). This deficient practice resulted in certifying patients for hospice services without documentation from the primary physician to support the diagnoses and enrolling patients who may not be qualified for the Medicare hospice benefits. Ensure the interdisciplinary group (team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) were notified of the missed home visits for the six of 14 sampled patients, (Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). This failure had the potential to a poor-quality care that can affect the quality of life of the affected patients receiving the end of life care. (Refer to L554). 4. The hospice agency failed to ensure home visits were conducted according to the plan of care for six of 14 sampled patients (Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). (Refer to L555). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the Federal regulations for IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services. --- .

Based on interview and record review, the hospice agency (an agency providing care to terminally ill patients who have six months or less to live) failed to ensure the interdisciplinary group (IDG) meetings were held by all the members of the IDG to discuss the patients comprehensive and ongoing assessments and care planning process for 11 of 14 sampled patients (Patients 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13). This deficient practice had the potential for Patient 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, and 13 health progress or health decline not to be identified by the IDG and had the potential for interventions not be implemented and patient care goals not to be achieved. --- Findings: c. A review of Patient 8's clinical record indicated he was admitted to the hospice agency on 3/20/2023, with a terminal diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in your body, called your aorta). A review of Patient 8s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/12/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus 2 prn (pro re nata, which means ";as needed") visits, hospice aide to 3 times a week, and the Master of Social Work (MSW ) to 1 visit as needed and recertification. There was no frequency of visits for the volunteer and the spiritual counselor or chaplain (SC). A review of Patient 8s POC/IDG meeting record indicated the Medical Director (MD) did not attend the meeting on 7/26/2023, and the chaplain (SC) did not attend the IDG meetings on 7/26/2023, 7/12/2023, 6/28/2023, 6/14/2023, and 5/31/2023. d. A review of Patient 9's clinical record indicated a start of care (SOC) date of 10/14/2022, with a terminal diagnosis of Parkinsons disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 9s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week plus 3 prn visit, hospice aide to 3 visits per week, MSW to one time or as needed for psychosocial support and assistance, and SC to once a month and as needed to offer spiritual and emotional support. Volunteer service was declined. A review of Patient 9s POC/IDG meeting record indicated the Medical Director did not attend the meeting on 7/26/2023. e. A review of Patient 10's clinical record indicated a start of care (SOC) date of 4/05/2023, with a terminal diagnosis of atherosclerosis of aorta. A review of Patient 10s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week plus 3 prn visits, hospice aide to 2 visits per week, MSW to one as needed and on recert (Recertification), and SC to one per month and 1 prn visit. A review of Patient 10s POC/IDG meeting record indicated the Medical Director did not attend the meeting on 7/26/2023. f. A review of Patient 11's clinical record indicated a start of care (SOC) date of 2/10/2023, with a terminal diagnosis of senile degeneration of brain, not elsewhere classified (the mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age). A review of Patient 11s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to two visits per week plus 1 prn visit, hospice aide to 2 visits per week, MSW to one as needed and recert, and SC to one per month plus 1 prn visit. A review of Patient 11s POC/IDG meeting record indicated the Medical Director did not attend the meeting on 7/26/2023. g. A review of Patient 12's clinical record indicated a start of care (SOC) date of 5/16/2023, with a terminal diagnosis of heart failure, unspecified (a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 12s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week plus 3 prn visits, hospice aide to 2 visits per week, MSW to one as needed and recert, and SC to one per month plus 3 prn visit. A review of Patient 12s POC/IDG meeting record indicated the Medical Director did not attend the meeting on 7/26/2023. h. A review of Patient 13's clinical record indicated a start of care (SOC) date of 1/02/2023, with a terminal diagnosis of senile degeneration of brain, not elsewhere classified. A review of Patient 13s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week plus 1 prn visit, hospice aide to 3 visits per week, MSW and SC to one visit as needed. A review of Patient 13s POC/IDG meeting record indicated the Medical Director did not attend the meeting on 7/26/2023. On 8/11/2023, at 11:20 a.m., during an interview with the Director of Patient Care Services (DPCS), DPCS stated the IDG meeting is done every two weeks and the members include the Medical Director, Social Worker, Chaplain, and Registered Nurse. The DPCS stated members who attended the meeting either physically sign in person, or electronically. DPCS further stated the IDG meetings should be signed on the same day the meeting was held. The DPCS was not able to provide documented evidence all the IDG members had participated in the IDG meeting for Patient 8, 9, 10, 11, 12 and 13 on the above days. A review of the agency's policy and procedure titled, "Interdisciplinary Group Meeting," revised November 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. Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor. a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 07/10/2023 and an end of care date (EOC) of 07/29/2023, with diagnosis of malignant neoplasm of colon (cancer of the colon). A review of Patient 1s POC/IDG form dated 7/12/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus 3 prn (pro re nata, which means ";as needed") visits. Further review of the POC/IDG form indicated that the physician and chaplain signatures were blank. A review of the IDG Sign In Sheet dated 07/12/2023, indicated that there was no signature for the Medical Director and chaplain. The IDG Sign In Sheet further indicated that the section where the signatures should be had ";virtual" written. A review of Patient 1s POC/IDG form dated 7/26/2023, indicated the frequency of visits of skilled nurse (SN) daily visits for symptom management times three days. Further review of the POC/IDG form indicated that the physician, registered nurse (RN) and chaplain signatures were blank. A review of the IDG Sign In Sheet dated 07/26/2023, indicated that there was no signature for the Medical Director and chaplain. The IDG Sign In Sheet further indicated that the section where the signatures should be had ";virtual" written. b. A review of Patient 4's clinical record indicated a start of care date (SOC) of 09/12/2022, with diagnosis of senile degeneration of the brain (senile degeneration of the brain). A review of Patient 4s POC/IDG form dated 7/26/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus 3 prn visits. Further review of the POC/IDG form indicated that the physician and registered nurse (RN) signatures were blank. A review of the IDG Sign In Sheet dated 07/26/2023, indicated that there was no signature for the Medical Director and the section where the signature should be had ";virtual" written. c. A review of Patient 5's clinical record indicated a start of care date (SOC) of 05/16/2023, with diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in your body, called your aorta). A review of Patient 5s POC/IDG form dated 05/31/2023, 06/14/2023, 06/28/23 and 07/12/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus 3 prn visits. Further review of the POC/IDG form indicated that the Master of Social Work (MSW) and chaplain signatures were blank. A review of the IDG Sign In Sheet dated 05/31/2023, 06/14/2023, 06/28/23 and 07/12/2023, indicated that there was no signature for the MSW and chaplain. The IDG Sign In Sheet further indicated that the section where the signatures should be had ";virtual" written. A review of Patient 5s POC/IDG form dated 07/26/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus 3 prn visits. Further review of the POC/IDG form indicated that the physician, Master of Social Work (MSW) and chaplain signatures were blank. A review of the IDG Sign In Sheet dated 07/26/2023, indicated that there was no signature for the physician, MSW and chaplain. The IDG Sign In Sheet further indicated that the section where the signatures should be had ";virtual" written. d. A review of Patient 6's clinical record indicated a start of care date (SOC) of 06/21/2023, with diagnosis of hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 6s POC/IDG form dated 06/28/23 and 07/12/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus one prn visit. Further review of the POC/IDG form indicated that the chaplain signature was blank. A review of the IDG Sign In Sheet dated 06/28/23 and 07/12/2023, indicated that there was no signature for the chaplain and the section where the signatures should be had ";virtual" written. A review of Patient 6s POC/IDG form dated 07/26/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus one prn visit. Further review of the POC/IDG form indicated that the physician, RN and chaplain signatures were blank. A review of the IDG Sign In Sheet dated 07/26/2023, indicated that there was no signature for the physician and chaplain. The IDG Sign In Sheet further indicated that the section where the signatures should be had ";virtual" written. e. A review of Patient 7's clinical record indicated a start of care date (SOC) of 06/08/2023, with diagnosis of hypertensive heart disease with heart failure. A review of Patient 7s POC/IDG form dated 06/28/23 and 07/12/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus one prn visit. Further review of the POC/IDG form indicated that the chaplain signature was blank. A review of the IDG Sign In Sheet dated 06/28/23 and 07/12/2023, indicated that there was no signature for the chaplain and the section where the signatures should be had ";virtual" written. A review of Patient 7s POC/IDG form dated 07/26/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus one prn visit. Further review of the POC/IDG form indicated that the physician and chaplain signatures were blank. A review of the IDG Sign In Sheet dated 07/26/2023, indicated that there was no signature for the physician and chaplain. The IDG Sign In Sheet further indicated that the section where the signatures should be had ";virtual" written.

Based on interview, and record review, the hospice agency failed to ensure the frequency of Spiritual Counsellor (a person who meets the psychosocial and spiritual needs of a patient) visits necessary to meet the spiritual needs of one of 14 sampled patients, (Patient 8) was indicated in the hospice plan of care (the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers). This deficient practice had the potential that patient's spiritual needs will not be met that could negatively affect the patients quality of life. --- A review of Patient 8's clinical record indicated he was admitted to the hospice agency on 3/20/2023, with a terminal diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in the body). A review of Patient 8s Plan of Care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 4/05/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus 2 prn (as needed) visits, hospice aide to 3 times a week, the Master of Social Work (MSW ) to 1 visit as needed and recertification, and Volunteer service was declined. The POC/IDG did not indicate the frequency of visits by the Spiritual Counselor (SC). Patient 8's POC/IDG form from 5/31/2023 to 7/26/2023 indicated no frequency of SC visit was included in the POC. A review of the History of Spiritual Assessment indicated the Spiritual Counselor (SC) did the comprehensive assessment of Patient 8 on 3/24/2023. On 8/11/2023, at 11:20 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS was not able to provide documented evidence that the frequency of visits of SC service was included in the POC for Patient 8. DPCS stated the frequency of visits of hospice care team that includes SC services should have been included in the POC. A review of the agency's policy and procedure titled "The Plan of Care", revised November 2020, indicated 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 patients and family/caregivers needs.

Based on interview and record review, the hospice agency failed to follow its policies and procedures by failing to: 1. Ensure the primary care physician verified the patients hospice (patients who are terminally ill and has six months or less to live) eligibility for hospice care and services for four of 14 sampled patients, (Patient 1, 5, 6 and 7). This deficient practice resulted in certifying patients for hospice services without documentation from the primary physician to support the diagnoses and enrolling patients who may not be qualified for the Medicare hospice benefits. 2. Ensure the interdisciplinary group (team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) were notified of the missed home visits for the six of 14 sampled patients, (Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). This failure had the potential to a poor-quality care that can affect the quality of life of the affected patients receiving the end of life care. --- Findings: a. A review of Patient 8's clinical record indicated he was admitted to the hospice agency on 3/20/2023, with a terminal diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in your body, called your aorta). A review of Patient 8s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 4/05/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus 2 prn (pro re nata, which means ";as needed") visits to assess and monitor cardiac status, nutritional status, effectiveness of medications, and pain and severity on every visit. A review of Patient 8s history of SN visits for the month of May 2023, indicated for the week starting on 5/07/2023 (Sunday) and ending on 5/13/2023 (Saturday), there was no SN visit conducted. A further review of Patient 8s clinical record indicated there was no documented evidence that the agencys nursing staff had notified or communicated with the IDG about the missed visit according to the agencys policy and procedure. b. A review of Patient 9's clinical record indicated a start of care (SOC) date of 10/14/2022, with a terminal diagnosis of Parkinsons disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 9s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week plus 3 prn visit, to assess and monitor cardiac status, nutritional status, safety concerns or issues, and effectiveness of current and new medication or treatment on every visit. A review of Patient 9s history of SN visits for the month of July 2023, indicated for the week starting on 7/23/2023 (Sunday) and ending on 7/29/2023 (Saturday), there was no SN visit conducted. A further review of Patient 9s clinical record indicated there was no documented evidence that the agencys nursing staff had notified or communicated with the IDG about the missed visit according to the agencys policy and procedure. c. A review of Patient 10's clinical record indicated a start of care (SOC) date of 4/05/2023, with a terminal diagnosis of atherosclerosis of aorta. A review of Patient 10s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week plus 3 prn visits, to assess and monitor cardiac status, nutritional status, safety concerns or issues, and effectiveness of current and new medication or treatment on every visit. A review of Patient 10s history of SN visits for the period starting May 2023 to July 2023, indicated the following: 1. For the week starting on 5/28/2023 (Sunday) and ending on 6/03/2023 (Saturday) – no SN visit was conducted. 2. For the week starting on 7/16/2023 (Sunday) and ending on 7/22/2023 (Saturday) – no SN visit was conducted. A further review of Patient 10s clinical record indicated there was no documented evidence that the agencys nursing staff had notified or communicated with the IDG about the missed visit according to the agencys policy and procedure. d. A review of Patient 11's clinical record indicated a start of care (SOC) date of 2/10/2023, with a terminal diagnosis of senile degeneration of brain, not elsewhere classified (the mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age). A review of Patient 11s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week plus 1 prn visit, to assess safety concerns and issues, to assess and monitor changes in neurological and/or sensory status, and effectiveness of current and new medication or treatment on every visit. A review of Patient 11s history of SN visits for the month of July 2023, indicated for the week starting on 7/16/2023 (Sunday) and ending on 7/22/2023 (Saturday), there was no SN visit conducted. A further review of Patient 11s clinical record indicated there was no documented evidence that the agencys nursing staff had notified or communicated with the IDG about the missed visit according to the agencys policy and procedure. e. A review of Patient 12's clinical record indicated a start of care (SOC) date of 5/16/2023, with a terminal diagnosis of heart failure, unspecified (a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 12s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week plus 3 prn visits, hospice aide to 2 visits per week, MSW to one as needed and recert, and SC to one per month plus 3 prn visit. A review of Patient 12s history of SN visits for the month of July 2023, indicated for the week starting on 7/23/2023 (Sunday) and ending on 7/29/2023 (Saturday), there was no SN visit conducted. A further review of Patient 12s clinical record indicated there was no documented evidence that the agencys nursing staff had notified or communicated with the IDG about the missed visit according to the agencys policy and procedure. f. A review of Patient 13's clinical record indicated a start of care (SOC) date of 1/02/2023, with a terminal diagnosis of senile degeneration of brain, not elsewhere classified. A review of Patient 13s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week plus 1 prn visit, to assess safety concerns and issues, to assess and monitor changes in neurological and/or sensory status, pain and severity, and effectiveness of current and new medication or treatment on every visit. A review of Patient 13s history of SN visits for the month of July 2023, indicated for the week starting on 7/16/2023 (Sunday) and ending on 7/22/2023 (Saturday), there was no SN visit conducted. A further review of Patient 13s clinical record indicated there was no documented evidence that the agencys nursing staff had notified or communicated with the IDG about the missed visit according to the agencys policy and procedure. On 8/11/2023, at 11:20 a.m., during an interview with the Director of Patient Care Services (DPCS), DPCS acknowledged the finding and stated patient care visit should be provided to patients according to the plan of care. The DPCS stated for any missed visits, IDG should be notified promptly by the field nurses and notification should be documented in the patients electronic records per the agencys policies and procedures. A review of the agencys policy and procedure titled, ";Missed Visits", revised November 2022, indicated missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a visit is missed and not rescheduled, the clinician will notify the IDG and clinical supervisor of the missed visit and reason for missed visit and will document in the patients clinical record. A review of the agencys policy and procedure titled, ";Interdisciplinary Group Coordination of Care", revised November 2020, indicated the hospice interdisciplinary group will retain professional management responsibilities for the provision of services, including inpatient care, and will ensure that services are furnished in a safe and effective manner. Written evidence of care coordination will be found in the plan of care and/or interdisciplinary team meeting forms in the patients clinical record, and will involve the hospice patients attending physician. Findings: a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 07/10/2023 and an end of care date (EOC) of 07/29/2023, with diagnosis of malignant neoplasm of colon (cancer of the colon). A review of Patient 1s POC/IDG form dated 7/26/2023, indicated the frequency of visits of skilled nurse (SN) daily visits for symptom management times three days. A review of Patient 1s ";Physicians Certification for Hospice Benefit" dated 07/10/2023 indicated that the Director of patient Care Services (DPCS) obtained verbal authorization from Physician 1. The verbal authorization indicated that Patient 1 was being referred to hospice and it was the physicians clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. The ";Physicians Certification for Hospice Benefit" further indicated that Physician 1 did not want to follow the patient. b. A review of Patient 5's clinical record indicated a start of care date (SOC) of 05/16/2023, with diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in your body, called your aorta). A review of Patient 5s POC/IDG form dated 07/26/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus 3 prn visits. A review of Patient 5s ";Physicians Certification for Hospice Benefit" dated 05/16/2023 indicated that the Director of patient Care Services (DPCS) obtained verbal authorization from Physician 1. The verbal authorization indicated that Patient 5 was being referred to hospice and it was the physicians clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. The ";Physicians Certification for Hospice Benefit" further indicated that Physician 1 did not want to follow the patient. c. A review of Patient 6's clinical record indicated a start of care date (SOC) of 06/21/2023, with diagnosis of hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 6s POC/IDG form dated 07/26/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus one prn visit. A review of Patient 6s ";Physicians Certification for Hospice Benefit" dated 06/21/2023 indicated that the Registered Nurse (RN 1) obtained verbal authorization from Physician 1. The verbal authorization indicated that Patient 6 was being referred to hospice and it was the physicians clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. The ";Physicians Certification for Hospice Benefit" further indicated that Physician 1 did not want to follow the patient. d. A review of Patient 7's clinical record indicated a start of care date (SOC) of 06/08/2023, with diagnosis of hypertensive heart disease with heart failure. A review of Patient 7s POC/IDG form dated 07/26/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus one prn visit. A review of Patient 7s ";Physicians Certification for Hospice Benefit" dated 06/08/2023 indicated that the Registered Nurse (RN 1) obtained verbal authorization from Physician 1. The verbal authorization indicated that Patient 7 was being referred to hospice and it was the physicians clinical judgement that the patient had a life expectancy of six months or less if the terminal illness runs its normal course. The ";Physicians Certification for Hospice Benefit" further indicated that Physician 1 did not want to follow the patient. During an interview with Physician 1 on 08/11/2023, at 10:12 a.m. he stated that he checked his records regarding Patients 1, 5, 6 and 7 and that he could not locate patients in his records. Physician 1 further stated that he did not refer Patients 1, 5, 6 and 7 to hospice and he was concerned how the agency got his signature. During an interview with the previous Medical Director (MD 1) on 08/11/2023, at 4:05 p.m., he stated that when he is contacted by the agency it is already determined that patient is eligible for hospice and agency just needs him for confirmation. Medical Director (MD 1) further stated that he does not communicate with the referring physician/primary care physician (PCP). A review of the agencys policy and procedure titled "Admission Criteria and Process", dated 11/2022, indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria developed by LCD (Local Coverage Determination) A review of the agencys policy and procedure titled "Physician Services – Attending Physicians Role", dated 11/2020, indicated that the role of the attending physician will include approving the referral of the patient and family/caregiver to the hospice program and provide written initial certification of the terminal illness and once the patient and family/caregiver chooses a hospice provider the attending physician will notify the hospice program and make a referral. The policy and procedure further indicated that the plan of care will be developed by the hospice registered nurse, the patient and family/caregiver, attending physician and hospice Medical Director after the initial assessment is performed prior to start of care.

Based on interview and record review, the hospice agency (HA) failed to ensure home visits were conducted according to the plan of care (POC) for six of 14 sampled patients (Patients 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). This failure had the potential to negatively affect the patients' physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. --- Findings: a. A review of Patient 8's clinical record indicated patient was admitted to the hospice agency on 3/20/2023, with a terminal diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in the body, called aorta). A review of Patient 8s POC (Plan of Care)/IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) form dated 4/05/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week and two as needed (prn) visits to assess and monitor cardiac status, nutritional status, effectiveness of medications, and pain and severity on every visit. A review of Patient 8s SN visits for the month of May 2023, indicated for the week of 5/07/2023 (Sunday) and ending on 5/13/2023 (Saturday), there was no SN visit conducted. b. A review of Patient 9's clinical record indicated a start of care (SOC) date of 10/14/2022, with a terminal diagnosis of Parkinsons disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 9s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week and three as needed (prn) visit, to assess and monitor cardiac status, nutritional status, safety concerns or issues, and effectiveness of current and new medication or treatment on every visit. A review of Patient 9s SN visits for the month of July 2023, indicated for the week starting on 7/23/2023 (Sunday) and ending on 7/29/2023 (Saturday), there was no SN visit conducted. c. A review of Patient 10's clinical record indicated an SOC date of 4/5/2023, with a terminal diagnosis of atherosclerosis of aorta. A review of Patient 10s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week and three as needed (prn) visits, to assess and monitor cardiac status, nutritional status, safety concerns or issues, and effectiveness of current and new medication or treatment every visit. A review of Patient 10s SN visits for the period starting May 2023 to July 2023, indicated the following: 1. For the week of 5/28/2023 (Sunday) and ending on 6/3/2023 (Saturday), no SN visit was conducted. 2. For the week of starting on 7/16/2023 (Sunday) and ending on 7/22/2023 (Saturday), no SN visit was conducted. d. A review of Patient 11's clinical record indicated an SOC date of 2/10/2023, with a terminal diagnosis of senile degeneration of brain, not elsewhere classified (the mental deterioration [loss of intellectual ability] that is associated with or the characteristics of old age). A review of Patient 11s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week and one as needed (prn) visit, to assess safety concerns and issues, to assess and monitor changes in neurological and/or sensory status, and effectiveness of current and new medication or treatment on every visit. A review of Patient 11s SN visits for the month of July 2023, indicated for the week starting on 7/16/2023 (Sunday) and ending on 7/22/2023 (Saturday), there was no SN visit conducted. e. A review of Patient 12's clinical record indicated an SOC date of 5/16/2023, with a terminal diagnosis of unspecified heart failure (a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 12s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week and three as needed (prn) visits. A review of Patient 12s SN visits for the month of July 2023, indicated for the week starting on 7/23/2023 (Sunday) and ending on 7/29/2023 (Saturday), there was no SN visit conducted. f. A review of Patient 13's clinical record indicated an SOC date of 1/2/2023, with a terminal diagnosis of senile degeneration of brain, not elsewhere classified. A review of Patient 13s POC/IDG form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week and one as needed (prn) visit, to assess safety concerns and issues, to assess and monitor changes in neurological and/or sensory status, pain and severity, and effectiveness of current and new medication or treatment on every visit. A review of Patient 13s SN visits for the month of July 2023, indicated for the week starting on 7/16/2023 (Sunday) and ending on 7/22/2023 (Saturday), there was no SN visit conducted. On 8/11/2023, at 11:20 a.m., during an interview with the Director of Patient Care Services (DPCS), DPCS acknowledged the findings and stated patient care visit should be provided to patients in accordance with the plan of care. A review of the agency's policy and procedure titled, "The Plan of Care", revised November 2020, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on interview and record review, the hospice agency failed to provide post-death bereavement assessment and counseling for the patients family for one of 14 sample patients (Patient 1). This deficient practice resulted in the patients bereaved family not receiving the support, counselling, and needs/resources after the patient's passing. --- Findings: A review of Patient 1's clinical record indicated a start of care date (SOC) of 07/10/2023 and an end of care date (EOC) of 07/29/2023, with diagnosis of malignant neoplasm of colon (cancer of the colon). A review of Patient 1s POC/IDG form dated 7/26/2023, indicated the frequency of visits of skilled nurse (SN) daily visits for symptom management times three days. A review of Patient 1s clinical record indicated that there was no post-death bereavement assessment and counseling for the patients family. During a concurrent record review and interview with the Director of Patient Care Services (DPCS), on 08/11/2023 at 3:20 p.m., he stated that Patient 1s family did not have a post-death bereavement assessment and counseling in the agencys electronic charting system. DPCS further stated that the post-death bereavement assessment and counseling should be done within a week after patient passes away. A review of the agencys policy and procedure titled ";Bereavement Services," dated 11/2020, indicated that the purpose of the policy and procedure is to ensure that appropriate and coordinated bereavement services are provided to families/caregivers. The policy and procedure further indicated that the program would provide bereavement services to the families/caregivers of hospice patients both before and after patients death in accordance with the plan of care. Additionally, the policy and procedure indicated that three to five days after patients death, a bereavement assessment will be completed by the bereavement counselor following the family/caregiver.

Based on interview and record review, the hospice agency (HA) failed to ensure ordered hospice aide service was provided in accordance with the plan of care (POC) for one of 14 sampled patients (Patient 9). This failure has the potential to negatively affect the patient's physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. --- Findings: A review of Patient 9's clinical record indicated a start of care (SOC) date of 10/14/2022, with a terminal diagnosis of Parkinsons disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 9s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 7/12/2023, indicated the frequency of visits for skilled nurse to one visit per week plus 3 prn visit, hospice aide to 3 visits per week, MSW to one time or as needed for psychosocial support and assistance, and SC to once a month and as needed to offer spiritual and emotional support. Volunteer service was declined. A review of Patient 9s hospice aide visits for the month of July 2023, indicated for the week of 7/16/2023 (Sunday) and ending on 7/22/2023 (Saturday), two visits were rendered by the Hospice Aide instead of three visits. On 8/11/2023, at 11:20 a.m., during an interview with the Director of Patient Care Services (DPCS), DPCS acknowledged the finding and stated patient care visit should be provided to patients according to the plan of care. The DPCS further stated that if patient refused hospice aide visit, such refusal will be documented in the patients clinical record. DPCS was unable to provide documented evidence that Patient 9 or the patient caregiver refused hospice aide visit on the above days no visit was conducted. A review of the agency's policy and procedure titled, "The Plan of Care", revised November 2020, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on interview and record review, the hospice agency (HA) failed to ensure that a Registered Nurse (RN) supervisory visit for hospice aide was conducted every 14 days for three of 14 sampled patients (Patient 8, Patient 9, and Patient 12) provided hospice aide services. This deficient practice resulted in lack of oversight of the hospice aides furnishing the care and services identified in the plan of care related to meeting the needs of the patient and family. . --- Findings: a. A review of Patient 8's clinical record indicated he was admitted to the hospice agency on 3/20/2023, with a terminal diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in your body, called your aorta). A review of Patient 8s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form dated 5/03/2023, indicated the frequency of visits of skilled nurse (SN) to one visit per week plus 2 prn (pro re nata, which means ";as needed") visits, hospice aide visit to 3 times a week, and the Master of Social Work (MSW ) to 1 visit as needed and recertification. Volunteer service was declined. A review of Patient 8's clinical record indicated that there was no hospice aide supervisory visit conducted by the RN on the dates between 4/27/2023 to 5/14/2023. b. A review of Patient 9's clinical record indicated a start of care date of 10/14/2022, with a terminal diagnosis of Parkinsons disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Patient 9s POC/IDG form dated 1/11/2023, indicated the frequency of visits for skilled nurse to 1 visit per week or 2 to 3 times per week as needed for pain and symptom management, and hospice aide to 3 visits per week. A review of Patient 9's clinical record indicated that there was no hospice aide supervisory visit conducted by the RN for the period starting on 1/19/23 to 2/01/2023. c. A review of Patient 12's clinical record indicated a start of care date of 5/16/2023, with a terminal diagnosis of heart failure, unspecified (a chronic condition in which the heart does not pump blood as well as it should). A review of Patient 12s POC/IDG form dated 5/31/2023, indicated the frequency of visits for skilled nurse to one visit per week plus 3 prn visits, hospice aide to 2 visits per week, MSW to one visit as needed, and the spiritual counselor (SC) to one visit per month plus 1 prn visit. A review of Patient 12's clinical record indicated that there was no hospice aide supervisory visit conducted by the RN for the period starting on 6/06/2023 to 6/19/2023. On 8/11/2023, at 11:20 a.m., during a concurrent interview and record review with the Director of Patient Care Services (DPCS), the DPCS stated hospice aide supervisory visit should be conducted every 14 days by the registered nurse. The DPCS was unable to provide documented evidence that a CHHA supervisory visit was conducted for Patient 8 on the dates from 4/27/2023 to 5/14/2023, for Patient 9 for the period starting on 1/19/23 to 2/01/2023, and for Patient 12 for the period starting on 6/06/2023 to 6/19/2023. A review of the agency's policy and procedure titled, "Hospice Aide Supervisory Visits", revised November 2020, indicated the hospice Case Manager will conduct supervisory visits to the patients residence at regular intervals. The frequency of supervisory visits will be based upon the needs of the patient after the plan of care is established. They must be conducted no less frequently than every 14 days. Supervisory visits and overall supervision will be documented in the clinical record.

Based on interview and record review, the hospice agency (agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Medical Director 1 (MD 1) or physician designee reviewed the clinical information for each patient necessary to support the initial certification of terminal illness (CTI, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less) for two of 14 sampled patients (Patients 1 and 6). This deficient practice resulted for Patients 1 and 6 to be admitted for hospice care without being evaluated by MD 1 and or physician designee to support their diagnosis of terminal illness. --- Findings: a. A review of Patient 1s ";Physicians Certification for Hospice Benefit," Certification number one, dated 7/10/2023 indicated the MD 1 did not sign the CTI attesting/confirming that he composed the narrative based on review of Patient 1s medical record, team assessment and/or examination of the patient. Further review of ";Physicians Certification for Hospice Benefit," indicated that face to face summary and certifying physician summary were blank. A review of Patient 1's clinical record indicated a start of care date (SOC) of 7/10/2023 and an end of care date (EOC) of 7/29/2023, with diagnosis of malignant neoplasm of colon (cancer of the colon). A review of Patient 1s 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) and the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) form dated 7/26/2023, indicated the frequency of visits of skilled nurse (SN) daily visits for symptom management times three days. b. A review of Patient 6s ";Physicians Certification for Hospice Benefit," Certification number one, dated 6/21/2023 indicated the MD 1 did not sign the CTI attesting/confirming that he composed the narrative based on review of Patient 6s medical record, team assessment and/or examination of the patient. A review of Patient 6's clinical record indicated a SOC of 6/21/2023, with diagnosis of hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 6s POC/IDG form dated 7/26/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus one as needed (PRN) visit. During a telephone interview with MD 1 on 8/11/2023, at 4:05 p.m., MD 1 stated the Registered Nurses (in general) created and prepared the patients CTIs (in general) and once completed he was notified, and he would then sign and review the CTIs. MD 1 stated he could not remember the reason he did not review nor sign Patient 1 and 6s CTIs. A review of the agencys policy and procedure titled ";Certification of Terminal Illness," dated 11/2020, indicated that the purpose of the policy and procedure is to ensure physician certification of terminal illness and authorization of hospice services, in accordance with applicable state and federal regulations and payer requirements. The policy and procedure further indicated that at the time of admission to hospice, the hospice Medical Director or patients attending physician will complete a certification narrative that reflects the patients individual circumstances based on his/her review of the patients medical record or, if applicable, examination of patient. Additionally, the policy and procedure indicated that the hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms and the certification must be complete no more than 15 calendar days prior to effective date of the hospice election statement.

Based on interview and record review, the hospice agency (agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Medical Director 1 (MD 1) or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness for four of 14 sampled patients (Patient 1, 5, 6 and 7). The deficient practice resulted for MD 1 certifying patients for hospice care without reviewing and verifying Patients 1, 5, 6 and 7's clinical information. --- Findings: a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 7/10/2023 and an end of care date (EOC) of 7/29/2023, with diagnosis of malignant neoplasm of colon (cancer of the colon). A review of Patient 1s medical record titled ";Physicians Certification for Hospice Benefit," dated 7/10/2023 indicated the Director of patient Care Services (DPCS) obtained a verbal authorization from Physician 1. The record indicated the verbal authorization indicated Patient 1 was being referred to hospice and it was Physician 1s clinical judgement if Patient 1 had a life expectancy of six months or less if the terminal illness ran its normal course. The ";Physicians Certification for Hospice Benefit," indicated Physician 1 did not want to follow Patient 1. A review of Patient 1s ";Physicians Certification for Hospice Benefit," Certification number one, dated 7/10/2023 indicated MD 1 did not sign the Certification of Terminal Illness (CTI, a brief narrative designed to explain clinical findings that support a life expectancy of six months or less) attesting/confirming he (MD 1) composed the narrative based on review of Patient 1s medical record, team assessment and/or examination of the patient. Further review of the ";Physicians Certification for Hospice Benefit," indicated the face-to-face summary and certifying physician summary were blank. A review of Patient 1s 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) and the Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) form dated 7/26/2023, indicated the frequency of visits of skilled nurse (SN) daily visits for symptom management times three days. b. A review of Patient 5's clinical record indicated a start of care date (SOC) of 5/16/2023, with diagnosis of atherosclerosis of aorta (a progressive buildup of plaque in the largest artery in your body). A review of Patient 5s ";Physicians Certification for Hospice Benefit," Certification number one, dated 5/16/2023 indicated MD 1 electronically signed on 5/16/2023 attesting/confirming he (MD 1) composed the narrative based on review of Patient 5s medical record, team assessment, and/or examination of Patient 5. A review of Patient 5s ";Physicians Certification for Hospice Benefit," dated 5/16/2023 indicated the DPCS obtained a verbal authorization from Physician 1. The form indicated the verbal authorization indicated Patient 5 was being referred to hospice and it was Physician 1s clinical judgement Patient 5 had a life expectancy of six months or less if the terminal illness ran its normal course. The ";Physicians Certification for Hospice Benefit," form indicated Physician 1 did not want to follow Patient 5. A review of Patient 5s POC/IDG form dated 7/26/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus three PRN (as needed) visits. c. A review of Patient 6's clinical record indicated a start of care date (SOC) of 6/21/2023, with diagnosis of hypertensive heart disease with heart failure (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 6s form titled ";Physicians Certification for Hospice Benefit," dated 6/21/2023 indicated the Registered Nurse 1 (RN 1) obtained a verbal authorization from Physician 1. The form indicated the verbal authorization indicated Patient 6 was being referred to hospice and it was Physician 1s clinical judgement Patient 6 had a life expectancy of six months or less if the terminal illness ran its normal course. The ";Physicians Certification for Hospice Benefit," further indicated Physician 1 did not want to follow Patient 6. A review of Patient 6s ";Physicians Certification for Hospice Benefit," Certification number one, dated 6/21/2023 indicated MD 1 did not sign the CTI attesting/confirming he (MD 1) composed the narrative based on review of Patient 6s medical record, team assessment and/or examination of Patient 6. A review of Patient 6s POC/IDG form dated 7/26/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus one PRN visit. d. A review of Patient 7's clinical record indicated a start of care date (SOC) of 6/8/2023, with diagnosis of hypertensive heart disease with heart failure. A review of Patient 7s medical record titled ";Physicians Certification for Hospice Benefit," dated 6/8/2023 indicated RN 1 obtained a verbal authorization from Physician 1. The record indicated the verbal authorization indicated Patient 7 was being referred to hospice and it was Physician 1s clinical judgement Patient 7 had a life expectancy of six months or less if the terminal illness ran its normal course. The ";Physicians Certification for Hospice Benefit," further indicated Physician 1 did not want to follow Patient 7. A review of Patient 7s ";Physicians Certification for Hospice Benefit," Certification number one, dated 6/8/2023 indicated MD 1 electronically signed on 6/8/2023 attesting/confirming MD 1composed the narrative based on review of Patient 7s medical record, team assessment, and/or examination of Patient 7. A review of Patient 7s POC/IDG form dated 7/26/2023, indicated the frequency of visits of skilled nurse (SN) to two visits per week plus one PRN visit. During a telephone interview with Physician 1 on 8/11/2023, at 10:12 a.m., Physician 1 stated he checked his records regarding Patients 1, 5, 6 and 7 (unidentified date) and stated he could not locate Patients 1, 5, 6 and 7 in his records. Physician 1 further stated he did not refer Patients 1, 5, 6 and 7 to hospice. During a telephone interview with MD 1 on 8/11/2023, at 4:05 p.m., MD 1 stated the hospice Registered Nurses (in general) would give him a synopsis (summary) of the patients (in general) history and he would determine hospice eligibility based on his knowledge and was aware of the hospice eligibility guidelines. MD 1 stated when the agency would contact him, it was already determined that patients (in general) were eligible for hospice. MD 1 stated the agency just needed MD 1s confirmation. Additionally, MD 1 stated he did not communicate with the referring physician/primary care physicians (PCP) for Patients 1, 5, 6 and 7. A review of the agencys policy and procedure titled "Admission Criteria and Process," dated 11/2022, indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria developed by LCD (Local Coverage Determination). A review of the agencys policy and procedure titled ";Physician Services – Medical Director," dated 11/2020, indicated that the purpose of the policy and procedure is to ensure qualified medical direction and consultation for the delivery of hospice services and programs. The policy and procedure further indicated that the purpose of the policy and procedure is to demonstrates that the medical director/hospice team physician has overall responsibility for patient care through documentation that demonstrates interaction/communication with attending physician as necessary for appropriate medical care.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Clinical Records was met as follows: 1. The hospice agency (HA) failed to ensure that agency staff submitted complete clinical notes in a timely manner for one of 14 sampled patients (Patient 1). (Refer to L672). 2. The hospice agency (HA) failed to ensure any amendments, correction or late entries within an electronic health record clearly identified the original content, the modified content, date, and authorship of each record modification for one of 14 sampled patients (Patient 1). (Refer to L679) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records wer safeguarded from unauthorized access by any individual or hospice staff and were maintained complete and accurate. --- .

Based on interview and record review, the hospice agency (HA) failed to ensure that agency staff submitted complete clinical notes in a timely manner for one of 14 sampled patients (Patient 1). The deficient practice resulted in patient not having a complete clinical record that could affect the continuity and coordination of care services. --- Findings: A review of Patient 1's clinical record indicated a start of care (SOC) date of 07/10/2023 and an end of care date (EOC) of 07/29/2023, with diagnosis of malignant neoplasm of colon (cancer [a disease in which abnormal cells divide uncontrollably and destroy body tissue] of the colon [large bowel]). A review of Patient 1s POC (Plan of Care)/IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) form dated 7/26/2023, indicated the frequency of visits of the skilled nurse (SN) daily visits for symptom management, times three days. On 08/08/2023, a review of Patients 1 Visit Notes indicated that there were only visit notes for 07/12/2023, 07/17/2023 and 07/21/2023 by the Licensed Vocational Nurse (LVN 2). Further review of Patient 1s Visit Notes indicated that there were no documentation by the Registered Nurse (RN 1). Patient 1's Visit Notes did not have any documentation regarding Patient 1s continuous care and post-mortem care. A review of Patient 1s Visit Notes dated 07/17/2023 and 07/21/2023, indicated that LVN 2 did not document patients temperature, pulse (number of heartbeats per minute), respiration (breathing), blood pressure (the pressure of circulating blood against the walls of blood vessels), and oxygen saturation (oxygen [gas essential for living] level in the blood). Visit Note LVN dated 7/17/2023 and 7/21/2023 was not signed and dated by LVN 2. A review of Patient 1s Home Health Aide Notes, indicated that there was no documentation made by the Certified Home Health Aide (CHHA 1). During an interview on 08/11/2023 at 11:13 a.m. and 11:42 am with Patient 1s Family Member (FM 1), FM1 stated that the nurse came and stayed with Patient 1 for three days (from 7/26/2023 to 7/28/2023) and that the nurse was with the patient from 7:00 p.m. to 7:00 a.m. Patient 1s Family Member (FM 1) further stated that on 07/29/2023 when Patient 1 passed away, there were two nurses from the agency who came and did the paperwork. During an interview on 8/11/2023 at 1:46 p.m. with the Certified Home Health Aide (CHHA 1), CHHA 1 stated that she worked with Patient 1 on Thursday and Friday from 7:00 p.m. to 7:00 a.m. The CHHA 1 stated that on Saturday when Patient 1 passed away, she was at the patients home from 5:30 p.m. to 8:30 p.m. CHHA 1 stated that she typed her continuous care notes and sent to the Licensed Vocational Nurse (LVN 2) and Administrator Designee (ADMD) via text message. CHHA 1 further stated that she did not document anything in the agencys electronic charting system and notes were sent to LVN 1 and ADMD. During an interview on 8/11/2023 at 3:14 p.m. and 3:24 p.m. with the Licensed Vocational Nurse (LVN 2), LVN 2 stated that her notes for Patient 1 were at home and she did not enter notes in the agencys electronic charting system. During a concurrent interview and record review on 08/11/2023 at 2:56 p.m., 3:20 p.m., and 3:31 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that LVN 2s paper charting was still with her, and that staff should submit notes within seven days. DPCS further stated that staff documentation should be in the agencys electronic charting system. DPCS stated that Patient 1 was not on continuous care and that CHHA 1 was a sitter, but there was no documentation from CHHA 1 in the agencys electronic charting system. A review of the agencys policy and procedure titled ";Contents of the Clinical Record" and dated 11/2020, indicated that the clinical record will be maintained for each patient receiving care and will contain sufficient information to identify the patient, describe the patients problem and needs, justify, accurately document care provided and results in detail, and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. The policy and procedure further indicated that each entry will be dated and signed, including title and credential, by the person providing care/service.

Based on interview and record review, the hospice agency (HA) failed to ensure any amendments, correction or late entries within the agency's electronic charting system must clearly identify the original content, the modified content, and date of each record modification for one of 14 sampled patients (Patient 1). This deficient practice had the potential to result in an unauthorized and inaccurate patient information or assessment in the patients' medical records that could affect the patient's quality of care and well-being. --- Findings: A review of Patient 1's clinical record indicated a start of care (SOC) date of 07/10/2023 and an end of care date (EOC) of 07/29/2023, with diagnosis of malignant neoplasm of colon (cancer [a disease in which abnormal cells divide uncontrollably and destroy body tissue] of the colon [large bowel]). A review of Patient 1s POC/(Plan of Care)/IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) form dated 7/26/2023, indicated the frequency of visits of the skilled nurse (SN) daily visits for symptom management, times three days. On 08/08/2023 at 1:10 p.m., a review of Patient 1s Discharge Summary dated 07/29/2023, indicated that Patient 1 had been reported to have a change of condition and nurse enroute to assess patient and was a candidate for continuous care. The Discharge Summary indicated that continuous care was started at 07/26/2023. The Discharge Summary was electronically signed by the Director of Patient Care Services Designee (DPCSD) on 07/29/2023. On 08/10/2023 12:10 p.m., another review was done of Patient 1s Discharge Summary dated 07/29/2023. The Discharge Summary was changed. The Discharge Summary indicated that "nurse enroute to assess patient and was a candidate for continuous care, however, family refused continuous care thus daily visits by Registered Nurse (RN) was made". The Discharge Summary was electronically signed by the Director of Patient Care Services Designee (DPCSD) on 07/29/2023. During a concurrent interview and record review on 08/11/2023 at 3:34 p.m. with the DPCSD, the DPCSD stated that she changed Patient 1s discharge summary notes on Wednesday, 8/9/2023, and forgot to write an addendum. A review of the agencys policy and procedure, titled ";Contents of the Clinical Record" and dated 11/2020, indicated that the clinical record will accurately document care provided and results in detail and facilitate continuity of care among hospice interdisciplinary group members and contract personnel. The policy and procedure further indicated that each entry will be dated and signed, including title and credential, by the person providing care/service.

It is required that the hospice Interdisciplinary Group, in consultation with the individual's attending physician (if any), completes an initial comprehensive assessment no later than five (5) calendar days after the election of hospice care. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed in which a comprehensive assessment was performed, revealed the hospice did not ensure that the interdisciplinary group completed the comprehensive assessment within 5 calendar days after the election of hospice care. Clinical Record 4 Election of hospice benefit dated 08/08/2022. The MSW documented the initial MSW assessment on 08/24/2022, 16 days after the election of hospice care. There was no documentation as to why the assessment was delayed beyond the 5 calendar days after the election of hospice care. Interview and record review with the Administrator (Owner/LVN) on 11/9/2022 confirmed this finding. The administrator said she spoke with the MSW who said she had tried to contact the family several times but did not document the phone calls.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff. The record may be maintained electronically or on paper. Each patient’s record includes, at a minimum physician's orders. This standard was not met as evidenced by a review of clinical records and interviews. 1 of 11 (9%) clinical records reviewed revealed the hospice did not ensure that physician orders were complete. Clinical Record 4 Election of hospice benefit dated 08/08/2022. Wound care orders for bilateral heel wounds (order dated 8/15/22) and sacral wound (order dated 8/31/22) did not include the frequency in which the dressing changes should occur. Interview and record review with the Administrator (Owner/LVN) on 11/9/2022 confirmed this finding. The administrator stated the EMR was new to them, and they were “still learning how to enter orders correctly.”