Every finding on record at Bright and White Hospice

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participations regarding Patient Rights was met as followed: --- 1. The HA failed to ensure written information regarding advance directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were obtained and informations were provided to fourteen (14) of 14 sampled patients, (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in patient and their family/caregivers not aware of the choices and wishes regarding medical treatment. (Refer to L503). 2. The HA failed to provide evidence that fourteen (14) of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) received or were informed of their patient rights and responsibilities. This failure had the potential to result in patient and their family/caregivers not aware of patient rights and responsibilities. (Refer to L504). 3. The HA failed to ensure 2 of 14 sampled patients (Patient 9 and Patient 13) were aware of all Medicare-covered hospice services (a program that gives special care to people who are near the end of life and have stopped treatment to cure or control their disease). This failure resulted in out-of-pocket expenses for medications that should have been covered under hospice services. (Refer to L518). The cumulative effect of these systemic practices resulted in patients not knowing their hospice services with their limitations and their rights as hospice patient.

Based on interview and record review, the Hospice Agency (HA) failed to ensure written information regarding advance directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were obtained and informations were provided to fourteen (14) of 14 sampled patients, (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in patient and their family/caregivers were not aware of the choices and wishes regarding medical treatment. --- a). A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). b). A review of Patient 2s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) with heart failure (heart not pumping enough blood for the body). c). A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (specific type of heart failure that occurs in the heart's left ventricle). d). A review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease without heart failure. e). A review of Patient 5s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/7/2024" with a hospice diagnosis of end stage heart failure (heart unable to pump adequately, shortness of breath, fatigue, and irregular heartbeat even while at rest). f) A review of Patient 6s medical record form titled ";Initial Orders and Plan of Care", indicated a start of care date on 1/22/2024 with a primary diagnosis of hypertensive heart disease without heart failure. g). A review of Patient 7s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/9/2024" with a hospice diagnosis of hypertensive heart disease without heart failure. h). A review of Patient 8s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease without heart failure (. i). A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure. During a home visit observation on 4/30/2024, at 10:15 a.m., the contents of Patient 9s agency folder contained blank forms. There were no evidence Patient 9 had received information about her rights. During an interview on 4/30/2024, at 10:21 a.m., caregiver (CG 1) stated he held the Durable Power of Attorney (DPOA, a document giving someone the ability to make important decisions) for Patient 9. During a concurrent interview and record review on 4/30/2024, at 10:57 a.m. during the home visit with Registered Nurse 1 (RN 1), Patient 9s agency folder was reviewed. RN 1 stated the agency folder did not contain copies of admission consents and patient rights. RN 1 asked Patient 9s family if they received the admission consents, Patient 9s family provided RN 1 carbon copies of documents titled, ";Rosewood Hospice & Palliative Care, Inc. (a different HA)". RN 1 stated the documents indicated Patient 9 had signed them on 12/28/2023. During an interview on 5/2/2024, at 11:45 a.m., the Director of Nurses designee (DD) stated the copies of the consents Patient 9 had, were from her previous hospice agency. The DD stated, Patient 9 was a new admission and required new consents to be signed. The DD stated there were no copies of Patient 9s DPOA documents. The DD stated it was important for Patient 9 and DPOA to have information about their rights because they are authorizing the HA to care for them. They should be aware of their rights. j). A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure. k). A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease with heart failure. l). A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). m). A review of Patient 13s record titled ";Bright and White Hospice", indicated a start of care date of 1/2/2024, with a primary diagnosis of hypertensive heart disease without heart failure. n). A review of Patient 14s record titled, ";Bright and White Hospice", indicated a start of care date on 1/2/2024, with a primary diagnosis of hypertensive heart disease without heart failure. During an interview on 4/29/2024, at 9:42 a.m., the Administrator (ADM) stated the paper charts of all the agencys hospice patients were stored at another business location. The ADM stated entity 1 (EN 1) took the paper documents in March 2024. During an interview on 4/29/2024 at 9:43 a.m. with the ADM, the ADM stated patients medical records were stored on their Electronic Medical Record (EMR) system. During an interview on 4/29/2024 at 11:15 a.m. with the ADM, the ADM stated the HAs physical medical records were confiscated (taken away) by Entity 1 (EN1) in March 2024. During a concurrent interview and record review on 4/30/2024 at 3:53 p.m. with the DD, the HAs EMR system were reviewed. The DD stated she was unable to locate Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14s signed advance directive information. The DD stated patients ";paper" records were taken away by EN1. The DD stated it was important to know what the patient wishes and choices of treatment were. A review of the HAs policy and procedure (P&P) titled, ";Patient Bill of Rights/ Responsibilities", dated April 2020, indicated, the patient Bill of Rights/Responsibilities statement defines the right of the patient to be informed of patient rights under state law to formulate Advance Directives. The P&P indicated, upon admission, the admitting clinician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights/Responsibilities in advance of furnishing care."

Based on interview and record review, the Hospice Agency (HA) failed to provide evidence for fourteen (14) of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) received or were informed of their patient rights and responsibilities This failure had the potential to result in patient and their family/caregivers not aware of patient rights and responsibilities. --- a). A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fats, cholesterol in artery walls, that affects the heart vessels with no chest pain). b). A review of Patient 2s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (changes to the left side of the heart) as a result of chronic blood pressure) with heart failure (heart not pumping enough blood for the body). c). A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (specific type of heart failure that occurs in the heart's left ventricle). d). A review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease without heart failure. e). A review of Patient 5s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/7/2024" with a hospice diagnosis of end stage heart failure (heart unable to pump adequately, shortness of breath, fatigue, and irregular heartbeat even while at rest). f) A review of Patient 6s medical record form titled ";Initial Orders and Plan of Care", indicated a start of care date on 1/22/2024 with a primary diagnosis of hypertensive heart disease without heart failure. g). A review of Patient 7s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/9/2024" with a hospice diagnosis of hypertensive heart disease without heart failure. h). A review of Patient 8s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease without heart failure (. i). A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure. During a home visit observation on 4/30/2024, at 10:15 a.m., the contents of Patient 9s agency folder contained blank forms. There were no evidence Patient 9 had received information about her rights. During an interview on 4/30/2024, at 10:21 a.m., caregiver (CG 1) stated he held the Durable Power of Attorney (DPOA, a document giving someone the ability to make important decisions) for Patient 9. During a concurrent interview and record review on 4/30/2024, at 10:57 a.m. during the home visit with Registered Nurse 1 (RN 1), Patient 9s agency folder was reviewed. RN 1 stated the agency folder did not contain copies of admission consents and patient rights. RN 1 asked Patient 9s family if they received the admission consents, Patient 9s family provided RN 1 carbon copies of documents titled, ";Rosewood Hospice & Palliative Care, Inc. (a different HA)". RN 1 stated the documents indicated Patient 9 had signed them on 12/28/2023. During an interview on 5/2/2024, at 11:45 a.m., the Director of Nurses designee (DD) stated the copies of the consents Patient 9 had, were from her previous hospice agency. The DD stated, Patient 9 was a new admission and required new consents to be signed. The DD stated there were no copies of Patient 9s DPOA documents. The DD stated it was important for Patient 9 and DPOA to have information about their rights because they are authorizing the HA to care for them. They should be aware of their rights. j). A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure. k). A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease with heart failure. l). A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). m). A review of Patient 13s record titled ";Bright and White Hospice", indicated a start of care date of 1/2/2024, with a primary diagnosis of hypertensive heart disease without heart failure. n). A review of Patient 14s record titled, ";Bright and White Hospice", indicated a start of care date on 1/2/2024, with a primary diagnosis of hypertensive heart disease without heart failure. During an interview on 4/29/2024, at 9:42 a.m., the Administrator (ADM) stated the paper charts of all the agencys hospice patients were stored at another business location. The ADM stated entity 1 (EN 1) took the paper documents in March 2024. During an interview on 4/29/2024 at 9:43 a.m. with the ADM, the ADM stated patients medical records were stored on their Electronic Medical Record (EMR) system. During an interview on 4/29/2024 at 11:15 a.m. with the ADM, the ADM stated the HAs physical medical records were confiscated (taken away) by Entity 1 (EN1) in March 2024. During a concurrent interview and record review on 4/30/2024 at 3:53 p.m. with the DD, the HAs EMR system were reviewed. The DD stated she was unable to locate Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14s signed advance directive information. The DD stated patients ";paper" records were taken away by EN1. The DD stated it was important to know what the patient wishes and choices of treatment were. A review of the HAs policy and procedure (P&P) titled, ";Patient Bill of Rights/ Responsibilities", dated April 2020, indicated, the patient Bill of Rights/Responsibilities statement defines the right of the patient to be informed of patient rights under state law to formulate Advance Directives. The P&P indicated, upon admission, the admitting clinician will provide each patient or his/her representative with a written copy of the Patient Bill of Rights/Responsibilities in advance of furnishing care."

Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure two of fourteen sampled patients (Patient 9 and Patient 13) were aware of all Medicare covered hospice services. This failure resulted in out-of-pocket expenses for medications that should have been covered under hospice services. --- a). A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an interview at the home visit on 4/30/2024, at 9:55 a.m., Registered Nurse 1 (RN 1) stated Patient 9 had heart failure, diabetes (abnormal blood sugar levels) and high blood pressure. During a medication review conducted during the home visit on 4/30/2024, at 10:30 a.m., Patient 9s medication bottles had a CVS pharmacy (name of pharmacy) label. During an interview at the home visit on 4/30/2024, at 10:40 a.m., the caregiver (CG1) stated all of Patient 9s medications are being picked up from CVS pharmacy and had to pay co-payments (a flat fee to fill prescriptions). CG1 stated he was not aware medications were covered by the HA. CG1 stated Patient 9 was taking Januvia for diabetes. CG1 stated Januvia medicine was very expensive at CVS pharmacy and the supply was only for one week. During an interview on 5/2/2024, at 11:30 a.m., the Director of Nurses designee (DD) stated she was aware Patient 9 needed Jardiance (medication to lower blood sugar) refilled. The DD stated she had asked another nurse to refill it. DD stated she had not followed up if the refill for Jardiance was done. The DD stated if Patient 9 missed her diabetic medication, her blood sugar could go up and Patient 9 could have complications such as ketoacidosis (a serious complication of diabetes), faint, headaches, vomiting, confusion, and disorientation. During a concurrent interview and record review on 5/3/2024, at 2:44 p.m. with the DD, Patient 9s record titled, ";Rx (prescription Delivery Receipt" was reviewed. The delivery receipt indicated the medication was delivered on 12/27/2023. The DD was unable to explain the delivery date was 12/27/2023 when the medications were requested on 1/2/2024. The DD stated the HA did not refill Patient 13s medication during the certification period of 1/2/2024 to 3/31/2024. b). A review of Patient 13s record titled ";Bright and White Hospice", indicated a start of care date on 1/2/2024, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure. During a concurrent interview and record review on 5/3/2024, at 10:08 a.m. with the DD, Patient 13s record titled, ";Initial Orders and Plan of Care", dated 1/2/2024 was reviewed. The record indicated Patient 13 was on insulin (a hormone medication that helps control blood sugar levels) for diabetes. The DD stated the record indicated the insulin order and other medications were sent to CVS pharmacy on 1/2/2024. A review of the HAs policy and procedure (P&P) titled, ";Scope of Services", dated April 2020, indicated, other covered services are available on a 24-hour basis to the extent necessary to meet the patients needs relating to palliation and treatment of the terminal illness and/or treatment of related conditions. The P&P indicated an interdisciplinary group of professionals and volunteers will develop with each patient and family/caregiver a plan of care, which will include, as appropriate, services for medications and medical supplies related to the hospice patients terminal diagnosis."

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessments of Patients was met as follows: --- On 5/3/2024 at 10:52 a.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the facilitys Director of Nurses Designee (DD). 1. The HA failed to assess all body systems, psychosocial, and spiritual needs of Patient 1, for certification period 1/5/2024-4/3/2024 to promote the patients well-being, comfort, and dignity throughout the dying process. Patient 1s clinical record did not have evidence of Patient 1s body system assessments and plan of care. 2. The HA failed to assess all body systems for Patient 3, for certification period 4/25/2024-6/23/2024 to promote the patients well-being, comfort, and dignity throughout the dying process. Patient 3s clinical record did not have evidence of the patients body system assessment and plan of care. 3. The HA failed to accurately assess Patient 4s diabetes status and other comorbidities, for certification period 3/1/2024-5/29/2024 to promote the patients well-being, comfort, and dignity throughout the dying process. Patient 4s clinical record did not have evidence of the patients blood sugar monitoring and plan of care. 4. The HA failed to assess all body systems, psychosocial and spiritual needs of Patient 8, for certification period 4/25/2024-6/23/2024 to promote the patients well-being, comfort, and dignity throughout the dying process. Patient 8s clinical record did not have evidence of the patients comprehensive assessment. Patient 8s clinical record did not have evidence of the patients body systems, psychosocial, and spiritual needs assessments. 5. The HA failed to accurately assess Patient 9s diabetes status for certification period 3/27/2024-6/24/2024 to promote the patients well-being, comfort, and dignity throughout the dying process. Patient 9s clinical record did not have evidence of blood sugar monitoring and plan of care. (Refer to L524). The cumulative effect of these systemic practices resulted in the Hospice Agency providing care without assessing and identifying the needs of the patients that can potentially affect the patients care and services that could lead to hospitalization and death.

Based on interview, observation, and record review, the Hospice Agency (HA) staff failed to conduct and document an accurate initial assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 7, Patient 8, Patient 9, and Patient 11). This failure resulted in patients being admitted without addressing all their immediate needs which is necessary to gather the essential information necessary to begin the plan of care and provide the immediate necessary care and services. --- 1. A review of Patient 1s record titled, ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During a concurrent interview and record review on 5/2/2024, at 1:30 p.m., the Director of Nurses Designee (DD) reviewed Patient 1s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/5/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. The areas not assessed were: Patient 1s height, weight, genitourinary (bladder, kidneys, urine) system, reproductive system, activities of daily living, and imminence of death. DD continued to review the record and indicated Patient 1 had not been assessed for his psychosocial status, spiritual assessment, and need for volunteer services. The areas ";Additional Nursing Observation" ";Skilled Care/Services Provided", ";Coordination of Care", ";Equipment/Supplies", ";The following are discussed with the patient and/or caregiver prior to provision of care", ";Plan of Care", ";Patient/Representative Instructions", ";Eligibility Assessment as Evidenced by", ";Teaching", and ";Need for Comprehensive Assessment" were left blank. A record review of Patient 1s document titled, ";Initial Orders and Plan of Care", dated 1/5/2024, did not indicate a plan of care was formulated. A record review of Patient 1s document titled, ";Certification of Terminal Illness", for certification period 1/5/2024 to 4/3/2024, indicated, ";I have reviewed and agree with the Plan of care that includes Initial Orders and Plan of Care, Medication Profile and Plan of Care Problems (identified in assessments) and admission to hospice." Further review of the record indicated Medical Director 2 (MD 2)s name. The record was not signed. During an interview on 5/3/2024, at 11:25 a.m. MD 2 stated he did not have any medical notes for Patient 1. MD 2 stated he had not seen and examined Patient 1. 2. A review of Patient 2s record titled, ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). A review of Patient 2s record form titled, ";Date Initial Nursing Assessment Initiated 1/5/2024" indicated sections ";Co-morbidities; Skin; Endocrine; and Attending Physician" were left blank. A review of Patient 2s record form titled, ";Initial Orders and Plan of Care" certification period from 1/5/2024 to 3/4/2024, indicated ";Hospice Admission Status – routine home care". The form did not indicate it was signed by a physician. 3. A review of Patient 3s record titled, ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). During a record review on 4/29/2024, at 1:20 p.m., Patient 3s record did not have a comprehensive assessment by the nurse for the current admission. During an interview on 5/2/2024, at 1:30 p.m., DD stated Patient 3 did not have a spiritual and psychosocial assessment because patient declined. DD stated an ";e-sign" (an electronic signature) on a document indicated it was authenticated/signed. During a concurrent interview and record review on 5/2/2024, at 1:34 p.m., the DD reviewed Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/12/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. The areas not assessed were: vital signs to include blood pressure, temperature, pulse, respiratory rate; current weight; functional limitation, activities permitted, mental status, memory recall, and skin. Further review of the record indicated, ";Need for Comprehensive Assessment", there was a check mark placed on ";Social Work" and ";Spiritual Care". During an interview and record review on 5/4/2024, at 11:50 a.m., DD submitted Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 4/25/2024. DD stated she had given the surveyor the initial nursing assessment from another certification period. DD provided document titled, ";Document History", printed on 5/4/2024 and indicated the assessment record was created on 4/30/2024, day 2 of the survey. A record review of Patient 3s record titled, ";";A0245. Date Initial Nursing Assessment Initiated", dated 4/25/2024, indicated ";Need for Comprehensive Assessment", nothing was selected. A record review of Patient 3s document titled, ";Initial Orders and Plan of Care", dated 4/25/2024, did not indicate a plan of care was formulated. A record review of Patient 3s document titled, ";Certification of Terminal Illness", for certification period 4/25/2024 to 6/23/2024, indicated, ";I have reviewed and agree with the Plan of care that includes Initial Orders and Plan of Care, Medication Profile and Plan of Care Problems (identified in assessments) and admission to hospice." Further review of the record indicated MD 2s name. The record was not signed because it did not indicate ";e-sign". During an interview on 5/3/2024, at 11:26 a.m. MD 2 stated he did not have any medical notes on Patient 3. MD 2 stated he had not seen and examined Patient 3. 4. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form untitled, indicated ";Initial Nursing Assessment Initiated 3/1/2024"; Certification period from 3/1/2024 to 5/29/2024. The following sections were left blank: POLST signed; Advance Directive; Allergies; and Co-morbidities Surgery dates. A review of Patient 4s record form titled ";Physician Order Details" dated 3/1/2024, indicated ";Admit patient... for the 1st benefit period...". The form did not indicate it was signed by a physician. During a review on 4/29/2024 at 1:23 p.m. of Patient 4s Electronic Medical Record (EMR) medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated the form was left blank. The form also indicted the signature sections for Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) were left blank. During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 4s home, LVN2 stated she visits Patient 4 twice a week for wound dressing change. LVN2 stated she did not have Patient 4s individualized plan of care. LVN2 stated she provided Patient 4s care by following the admitting nurse verbal instructions. LVN2 stated her visits include changing Patient 4s head wound dressing, checking his vital signs, and checking the facility for safety. Caretaker 1 (CT1) stated Patient 4 has not been seen by the HAs MSW or SC. CT1 stated Patient 4 was a Roman Catholic who attends church every Sunday and would benefit from SC services. CT1 stated Patient 4 would benefit from an MSW because he needs resources. During a concurrent interview and record review on 5/2/2024 at 11:13 a.m. with Medical Director 1 (MD1) of Patient 4s clinical notes, MD1 stated he did not dictate any notes for Patient 4. During a concurrent interview and record review on 5/2/2024 at 1:35 p.m. with DD of Patient 4s EMR, DD stated Patient 4 did not have a plan of care. DD stated Patient 4 needed to have a plan of care. During a concurrent interview and record review on 5/2/2024, at 2:14 p.m., with DD of Patient 4s EMR, DD stated Patient 4 did not have SC or MSW notes in his EMR. 5. A review of Patient 6s medical record form titled ";Initial Orders and Plan of Care", indicated a start of care date on 1/22/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). A review of Patient 6s record form titled, ";Date Initial Nursing Assessment Initiated 1/22/2024" indicated sections ";Allergies; HT; WT; MAC; and Co-morbidities" were left blank. A review of Patient 6s record form titled, ";Initial Orders and Plan of Care" certification period from 1/22/2024 to 3/21/2024, indicated ";Hospice Admission Status – routine home care". The form did not indicate it was signed by a physician. 6. A review of Patient 7s record form titled, ";Patient Basic Info" indicated ";Allergies: Cipro, Penicillin". A review of Patient 7s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/9/2024" with a hospice diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). The form also indicated ";Allergies: Penicillin." 7. A review of Patient 8s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 8s medical record form untitled, indicated ";Initial Nursing Assessment Initiated 4/25/2024" indicated it was not complete. The following areas were not assessed vital signs to include blood pressure, temperature, pulse, respiratory rate; current weight; functional limitation, activities permitted, mental status, memory recall, skin, musculoskeletal, sensory, cardiovascular, gastrointestinal, pain assessment, respiratory, endocrine, nutrition/hydration, genitourinary, reproductive, additional assessment, activity of daily living, psychosocial assessment, spiritual assessment, skilled care/Services provided, coordination of care, equipment/supplies, plan of care, eligibility assessment, teaching, need for comprehensive assessment, attending physician, and summary/plan/support diagnosis. A review of Patient 8s record form titled ";Physician Order Details" dated 4/25/2024, indicated ";Admit patient... for the 3rd benefit period from with a terminal ...". The form also indicated ";order read back and verified with physician" by DD. The form did not indicate it was signed by DD or at physician. During a concurrent interview and record review on 4/30/2024 at 3:15 p.m. with the DD of Patient 8s EMR, DD stated Patient 8s start of care date was 4/25/2024. DD stated she was unable to locate an initial nursing assessment for Patient 8 that was supposed to be completed by 4/25/2024. 8. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an interview at the home visit on 4/30/2024, at 9:55 a.m. Registered Nurse 1 (RN 1) stated Patient 9 had heart failure, diabetes (elevated levels of sugar in the blood), and high blood pressure. During an observation of the home visit on 4/30/2024, at 10:00 a.m. Patient 9 was sitting in a chair in the living room, covered in a blanket. Patient 9 was not using oxygen. During an interview at the home visit on 4/30/2024, at 10:10 a.m., RN 1 stated the goal of the visit was to assess for pain. During the visit, RN did not assess Patient 9s blood sugar levels and did not assess Patient 9 for symptoms of high (hyperglycemia) or low (hypoglycemia) blood sugar. RN 1 assessed Patient 9s oxygen saturation reading (a percentage to measure how much blood is flowing in the body). RN 1 stated the reading was 95% in room air (without the use of oxygen, using ambient air to breathe). During an observation of the home visit on 4/30/2024, at 10:10 a.m., RN 1 assisted Patient 9 to stand up from the chair. Patient 9 stood up and sat down with RN 1 assisting. During the period of standing to sitting, Patient 9s breathing pattern was unlabored, and no use of oxygen occurred. During an observation of the home visit on 4/30/2024, at 10:17 a.m., RN 2 assessed patient 9s arms and legs. RN 1 stated Patient 9 did not have edema (swelling) on either of the arms and legs. During a concurrent observation and interview during the home visit on 4/30/2024, at 10:21 a.m., RN 1 assessed Patient 9s upper chest. RN 1 stated there was a dry, white dressing on the upper right chest wall, with two ports coming out of the dressing. Patient 9s caregiver (CG 1) stated it was her access port for her dialysis (a clinical purification of blood, as a substitute for the normal function of the kidneys) treatment every Monday and Friday. During an interview at the home visit on 4/30/2024, at 10:40 a.m., CG 1 stated Patient 9s medication ";Januvia" was for her diabetes. During an interview on 5/2/2024, at 11:04 a.m., Medical Director 1 (MD 1) stated he was aware Patient 9 had diabetes. MD 1 stated he was expecting for the nursing staff to assess Patient 9s diabetes to make sure she was not getting hyperglycemic or hypoglycemic. MD 1 stated the nursing staff should report to him if there is anything unusual such as having hyper/hypo glycemia. MD 1 stated patients with diabetes should be monitored at least once a week. During a concurrent interview and record review on 5/2/2024, at 11:14 a.m., DD reviewed Patient 9s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 3/27/2024. DD reviewed section ";Endocrine" and stated the record indicated ";WNL" (within normal limits). DD stated the record should have had a narrative about diabetes to include blood sugar levels. DD stated the assessment focused on the heart failure. DD stated diabetes did have an effect on heart failure and should have been assessed. DD stated the system assessment was important because that is what was used to formulate the plan of care for the patient. Further review of the record indicated, Patient 9s qualifying criteria included an NYHA (New York Heart Association classification of heart failure) level 4 (the highest level of heart failure. Patient has symptoms at rest. If any physical activity is undertaken, physical discomfort increased). A record review of Patient 9s document titled, ";Initial Orders and Plan of Care", dated 3/27/2024, did not indicate a plan of care was formulated. During an interview on 5/2/2024, at 10:53 a.m., MD 1 stated that Patients with NYHA 4 are unable to walk more than 5 steps without being more than short of breath. If patients had right sided heart failure, he would expect edema. Patients with heart failure would benefit from continuous oxygen. A record review of Patient 9s document titled, ";Certification of Terminal Illness", for certification period 3/27/2024 to 6/24/2024, indicated, ";I have reviewed and agree with the Plan of care that includes Initial Orders and Plan of Care, Medication Profile and Plan of Care Problems (identified in assessments) and admission to hospice." Further review of the record indicated MD 2s name, not MD 1. The record was not signed because it did not indicate ";e-sign". 9. A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). A review of Patient 11s medical record form, indicated ";Date Initial Nursing Assessment Initiated 2/27/2024" indicated it was electronically signed on 3/27/2024. The form also indicated the following sections were left blank ";POLST signed; Advance Directive; HT; WT; MAC; and Co-morbidity." A review of Patient 11s record form titled, ";Initial Orders and Plan of Care" certification period from 2/27/2024 to 4/26/2024, indicated ";Hospice Admission Status – routine home care". The form also indicated sections ";Orders for discipline and treatments and DME" were left blank. The form did not indicate it was signed by a physician. A review of Patient 11s record form titled, ";Physician Order Details" dated 4/18/2024, indicated ";Recertify patient... for the 6th benefit period starting 4/27/2024 to 6/25/2024". The form also indicated ";order read back and verified with physician" by DD. The form did not indicate it was signed by DD or at physician. During an interview on 4/29/2024 at 9:43 a.m. with the Administrator (ADM), the ADM stated patients medical records were stored on their Electronic Medical Record (EMR) system. During an interview on 4/29/2024 at 11:15 a.m. with the ADM, the ADM stated the patients physical medical records were confiscated by Entity 1 (EN1) in March 2024. During an interview on 4/30/2024 at 12:55 p.m. with the DD, DD stated the HA sends a Registered Nurse to assess and formulate new incoming patients plan of care. A record review of the HAs policy and procedure titled, ";Comprehensive Assessment", dated April 2020, indicated, ";A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. Procedure: 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least the following information, as relevant: ...G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patients terminal illness...2. The assessment should determine: A. Probably prognosis of six (6) months or less. B. Patient problems and needs related to the terminal illness. C. Patient goals related to the terminal illness...". A record review of the HAs policy and procedure titled, ";Initial Assessment", dated April 2020, indicated, ";Policy: An initial assessment will be performed by a registered nurse within 48 hours after election of hospice...6. Admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during this initial assessment....7. Based on the initial assessment, the plan of care will be initiated on the day of admission. 8. The initial assessment will be filed in the patients clinical record."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after election of hospice care for eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 6, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). This failure resulted in patients not being properly evaluated which resulted in not being provided the individualized focused care. --- 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During a concurrent interview and record review on 5/2/2024, at 1:30 p.m., the Director of Nurses Designee (DD) reviewed Patient 1s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/5/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. DD continued to review the record and indicated Patient 1 had not been assessed for his psychosocial status, spiritual assessment, and need for volunteer services. The areas ";Additional Nursing Observation" ";Skilled Care/Services Provided", ";Coordination of Care", ";Equipment/Supplies", ";The following are discussed with the patient and/or caregiver prior to provision of care", ";Plan of Care", ";Patient/Representative Instructions", ";Eligibility Assessment as Evidenced by", ";Teaching", and ";Need for Comprehensive Assessment" were left blank. A record review of Patient 1s document titled, ";Initial Orders and Plan of Care", dated 1/5/2024, did not indicate a plan of care was formulated. Continued review of the record did not indicate orders for discipline and treatments, problems identified, for the physical, emotional, and psychosocial needs of Patient 1. 2. A review of Patient 2s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 2s medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 1/5/2024, indicated the Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) did not sign the form. 3. A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). During a record review on 4/29/2024, at 1:20 p.m., Patient 3s record did not have a comprehensive assessment by the nurse. During an interview on 4/30/2024, at 1:09 p.m., DD stated the IDG group documented the meeting in the electronic medical record (EMR) right away. Each discipline had their own computer access, and each discipline entered their own note in the EMR. During an interview on 5/2/2024, at 1:30 p.m., DD stated Patient 3 did not have a spiritual and psychosocial assessment because patient declined. DD stated an ";e-sign" (an electronic signature) on a document indicated it was authenticated/signed. During a concurrent interview and record review on 5/2/2024, at 1:34 p.m., the DD reviewed Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/12/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. Further review of the record indicated, ";Need for Comprehensive Assessment", there was a check mark placed on ";Social Work" and ";Spiritual Care". During an interview and record review on 5/4/2024, at 11:50 a.m., DD submitted Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 4/25/2024. DD stated she had given the surveyor the initial nursing assessment from another certification period. DD provided document titled, ";Document History", printed on 5/4/2024 and indicated the assessment record was created on 4/30/2024, day 2 of the survey. A record review of Patient 3s record titled, ";";A0245. Date Initial Nursing Assessment Initiated", dated 4/25/2024, indicated ";Need for Comprehensive Assessment", nothing was selected. A record review of Patient 3s document titled, ";Initial Orders and Plan of Care", dated 4/25/2024, did not indicate a plan of care was formulated. A record review of Patient 3s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/26/2024, did not indicate any narrative for the section ";Spiritual Care Report" and ";SW Report". Continued review of the record indicated the names of Medical Social Worker 1 (MSW 1), Medical Social Worker 2 (MSW 2), and SC. However, the document did not indicate ";e-sign" to indicate their presence and participation in the review of the comprehensive assessment and plan of care. 4. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review on 4/29/2024 at 1:23 p.m. of Patient 4s Electronic Medical Record (EMR) medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated the form was left blank. The form also indicted the signature sections for Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) were left blank. 5. A review of Patient 6s medical record form titled ";Initial Orders and Plan of Care", indicated a start of care date on 1/22/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 6s medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 1/22/2024, indicated the Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW 1 and MSW 2) did not sign the form. 6. A review of Patient 8s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 8s medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 4/26/2024, indicated the Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW1 and MSW 2) did not sign the form. 7. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an interview at the home visit on 4/30/2024, at 9:55 a.m. Registered Nurse 1 (RN 1) stated Patient 9 had heart failure, diabetes (elevated levels of sugar in the blood), and high blood pressure. During a concurrent interview and record review on 5/2/2024, at 11:14 a.m., DD reviewed Patient 9s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 3/27/2024. DD reviewed section ";Endocrine" and stated the record indicated ";WNL" (within normal limits). DD stated the record should have had a narrative about diabetes to include blood sugar levels. DD stated the assessment focused on the heart failure. DD stated diabetes did have an effect on heart failure and should have been assessed. DD stated the system assessment was important because that is what was used to formulate the plan of care for the patient. During an interview on 5/2/2024, at 1:52 p.m., DD stated Patient 9 did not have a spiritual and psychosocial assessment because the patient declined. A record review of Patient 9s record titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/5/2024, indicated, ";Spiritual Care Report: ";IDT 4/5/2024, Chaplain visits-Initial assessment within 5 days to provide support to patient and family. SW Report IDT 4/5/2024. MSW visits-Intial assessment within 5 days to provide psychosocial support to patient and family." Further review of the record indicated the names of MSW 1 and MSW 2. However, the document was not signed. A record review of Patient 9s document titled, ";Initial Orders and Plan of Care", dated 3/27/2024, did not indicate a plan of care was formulated. 8. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During an interview on 5/2/2024, at 2:11 p.m., DD stated Patient 10 did not have a spiritual and psychosocial assessment because the patient declined. A record review of Patient 10s document titled, ";A0245. Date Initial Nursing Assessment Initiated,", dated 1/2/2024, indicated, ";Need for Comprehensive Assessment", check mark selections were placed next to ";Social Work" and ";Spiritual Care". A record review of Patient 10s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 1/2/2024, indicated, ";Spiritual Care Report: IDT 1/2/2024, Chaplain visits-Initial assessment within 5 days to provide support to patient and family. SW Report IDT 1/2/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family." Further review of the record did not indicate entries in section ";Social Worker Name". 9. A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 11s medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated the Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW 1 and MSW 2) did not sign the form. 10. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). During an interview on 5/2/2024, at 2:15 p.m., DD stated Patient 12 did not have a spiritual and psychosocial assessment because the patient declined. A record review of Patient 12s document titled, ";A0245. Date Initial Nursing Assessment Initiated,", dated 1/9/2024, indicated, ";Need for Comprehensive Assessment", check mark selections were placed next to ";Social Work" and ";Spiritual Care". A record review of Patient 12s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 1/9/2024, indicated, ";Spiritual Care Report: IDT 1/9/2024, Chaplain visits-Initial assessment within 5 days to provide support to patient and family. SW Report IDT 1/9/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family." Further review of the document did not indicate any name for section ";Social Worker Name". 11. A review of Patient 13s record titled ";Bright and White Hospice", indicated a start of care date on 1/2/2024, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During an interview on 5/2/2024, at 2:16 p.m., DD stated Patient 13 did not have a spiritual and psychosocial assessment because the patient declined. A record review of Patient 13s document titled, ";A0245. Date Initial Nursing Assessment Initiated,", dated 1/2/2024, indicated, ";Need for Comprehensive Assessment", check mark selections were placed next to ";Social Work" and ";Spiritual Care". During an interview on 4/30/2024 at 12:55 p.m. with the Director of Nurses Designee (DD), DD stated the IDT meetings are conducted during admission and no later than the following day. DD stated the Registered Nurse (RN), office staff, Medical Social Worker (MSW), Spiritual Counselor (SC), and the doctor are called after the initial nursing assessment to verify patients medications, ancillaries, and DME (durable medical equipment: bed, oxygen, diapers, etc.). DD stated all disciplines have access with their personal log in information for the HAs Electronic Medical Record (EMR) system where they need to document their concerns and sign. During an interview on 5/2/2024 at 11:25 a.m., DD stated patients comprehensive assessment are a head-to-toe assessment that is used to initiate patients plan of care. A record review of the HAs policy and procedure titled, ";Spiritual Assessment", dated April 2020, indicated, ";Policy: A spiritual assessment will be completed for each patient/family by the Hospice Chaplain." A record review of the HAs policy and procedure titled, ";Psychosocial Assessment", dated April 2020, indicated, ";Policy...Psychosocial assessment will be completed by a qualified hospice social worker or hospice registered nurse." A record review of the HAs policy and procedure titled, ";Comprehensive Assessment", dated April 2020, indicated, ";Policy: A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the comprehensive assessments were complete for five of fourteen sampled patients (Patient 1, Patient 3, Patient 4, Patient 8, and Patient 9) by failing to: 1. Assess all body systems, psychosocial, and spiritual needs of Patient 1, for certification period 1/5/2024-4/3/2024, to promote the patients well-being, comfort, and dignity throughout the dying process. Patient 1s clinical record did not have evidence of Patient 1s body system assessments and plan of care. 2. Assess all body systems for Patient 3, for certification period 4/25/2024-6/23/2024 to promote the patients well-being, comfort, and dignity throughout the dying process. Patient 3s clinical record did not have evidence of the patients body system assessment and plan of care. 3. Accurately assess Patient 4s diabetes status and other comorbidities, for certification period 3/1/2024-5/29/2024, to promote the patients well-being, comfort, and dignity throughout the dying process. Patient 4s clinical record did not have evidence of the patients blood sugar monitoring and plan of care. 4. Assess all body systems, psychosocial and spiritual needs of Patient 8, for certification period 4/25/2024-6/23/2024, to promote the patients well-being, comfort, and dignity throughout the dying process. Patient 8s clinical record did not have evidence of the patients comprehensive assessment. Patient 8s clinical record did not have evidence of the patients body systems, psychosocial, and spiritual needs assessments. 5. Accurately assess Patient 9s diabetes status for certification period 3/27/2024-6/24/2024, to promote the patients well-being, comfort, and dignity throughout the dying process. No blood sugar checks done for Patient 9.. Patient 9s clinical record did not have evidence of blood sugar monitoring and plan of care. The deficient practices resulted in the Hospice Agency providing care without assessing and identifying the needs of the patients that could potentially affect the patients care and services that could lead to hospitalization and death. On 5/3/2024 at 10:52 a.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the facilitys Director of Nurses Designee (DD) related to the agency failure to conduct comprehensive assessment related to the promoting the hospice patients' well being throughout the dying process for five of fourteen sample patients (Patient 1, Patient 3, Patient 4, Patient 8, and Patient 9). On 5/4/2024 at 4:00 p.m., the survey team conducted an exit conference in the presence of the Director of Nurses Designee and Co-Owner and the IJ situation was not removed. The agency did not submit an acceptable Immediate Jeopardy Removal Plan upon exit. --- 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During a concurrent interview and record review on 5/2/2024, at 1:30 p.m., the Director of Nurses Designee (DD) reviewed Patient 1s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/5/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. The areas not assessed were: Patient 1s height, weight, genitourinary (bladder, kidneys, urine) system, reproductive system, activities of daily living, and imminence of death. DD continued to review the record and indicated Patient 1 had not been assessed for his psychosocial status, spiritual assessment, and need for volunteer services. The areas ";Additional Nursing Observation" ";Skilled Care/Services Provided", ";Coordination of Care", ";Equipment/Supplies", ";The following are discussed with the patient and/or caregiver prior to provision of care", ";Plan of Care", ";Patient/Representative Instructions", ";Eligibility Assessment as Evidenced by", ";Teaching", and ";Need for Comprehensive Assessment" were left blank. A record review of Patient 1s document titled, ";Initial Orders and Plan of Care", dated 1/5/2024, did not indicate a plan of care was formulated. 2. A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). During a record review on 4/29/2024, at 1:20 p.m., Patient 3s record did not have a comprehensive assessment by the nurse. During an interview on 5/2/2024, at 1:30 p.m., DD stated Patient 3 did not have a spiritual and psychosocial assessment because patient declined. During a concurrent interview and record review on 5/2/2024, at 1:34 p.m., the DD reviewed Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/12/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. The areas not assessed were: vital signs to include blood pressure, temperature, pulse, respiratory rate; current weight; functional limitation, activities permitted, mental status, memory recall, and skin. Further review of the record indicated, ";Need for Comprehensive Assessment", there was a check mark placed on ";Social Work" and ";Spiritual Care". During an interview and record review on 5/4/2024, at 11:50 a.m., DD submitted Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 4/25/2024. DD stated she had given the surveyor the initial nursing assessment from another certification period. DD provided document titled, ";Document History", printed on 5/4/2024 and indicated the assessment record was created on 4/30/2024, day 2 of the survey. A record review of Patient 3s record titled, ";";A0245. Date Initial Nursing Assessment Initiated", dated 4/25/2024, indicated ";Need for Comprehensive Assessment", nothing was selected. A record review of Patient 3s document titled, ";Initial Orders and Plan of Care", dated 4/25/2024, did not indicate a plan of care was formulated. 3. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form untitled, indicated ";Initial Nursing Assessment Initiated 3/1/2024"; Certification period from 3/1/2024 to 5/29/2024. The following sections were left blank: POLST signed; Advance Directive; Allergies; and Co-morbidities Surgery dates. During a review on 4/29/2024 at 1:23 p.m. of Patient 4s Electronic Medical Record (EMR) medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated the form was left blank. The form also indicted the signature sections for Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) were left blank. During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 4s home, LVN2 stated she visits Patient 4 twice a week for wound dressing change. LVN2 stated she did not have Patient 4s individualized plan of care. LVN2 stated she provided Patient 4s care by following the admitting nurse verbal instructions. LVN2 stated her visits include changing Patient 4s head wound dressing, checking his vital signs, and checking the facility for safety. Caretaker 1 (CT1) stated Patient 4 has not been seen by the HAs MSW or SC. CT1 stated Patient 4 was a Roman Catholic who attends church every Sunday and would benefit from SC services. CT1 stated Patient 4 would benefit from an MSW because he needs resources. During a concurrent interview and record review on 5/2/2024 at 11:13 a.m. with Medical Director 1 (MD1) of Patient 4s clinical notes, MD1 stated he did not dictate any notes for Patient 4. During a concurrent interview and record review on 5/2/2024 at 1:35 p.m. with DD of Patient 4s EMR, DD stated Patient 4 did not have a plan of care. DD stated Patient 4 needed to have a plan of care. During a concurrent interview and record review on 5/2/2024, at 2:14 p.m., with DD of Patient 4s EMR, DD stated Patient 4 did not have SC or MSW notes in his EMR. 4. A review of Patient 8s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 8s medical record form untitled, indicated ";Initial Nursing Assessment Initiated 4/25/2024" indicated it was not complete. The following areas were not assessed vital signs to include blood pressure, temperature, pulse, respiratory rate; current weight; functional limitation, activities permitted, mental status, memory recall, skin, musculoskeletal, sensory, cardiovascular, gastrointestinal, pain assessment, respiratory, endocrine, nutrition/hydration, genitourinary, reproductive, additional assessment, activity of daily living, psychosocial assessment, spiritual assessment, skilled care/Services provided, coordination of care, equipment/supplies, plan of care, eligibility assessment, teaching, need for comprehensive assessment, attending physician, and summary/plan/support diagnosis. During a concurrent interview and record review on 4/30/2024 at 3:15 p.m. with the DD of Patient 8s EMR, DD stated Patient 8s start of care date was 4/25/2024. DD stated she was unable to locate an initial nursing assessment for Patient 8 that was supposed to be completed by 4/25/2024. During a review of Patient 8s medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 4/26/2024, indicated there were no signatures in sections Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) were left blank. The form also indicated Medical Doctor 1 (MD1) and MD2s names were printed in section ";Physician Name, Signature, Date". During a joint home visit on 5/1/2024 at 9:20 a.m. with License Vocational Nurse 1 (LVN1) to Patient 8s home, Patient 8 refused the home visit stated she did not get a good rest the night before. Patient 8 noted fully dressed, tennis shoes at bed side, and sitting up on bed. During a concurrent interview and record review on 5/2/2024 at 10:48 a.m. with Medical Director 1 (MD1) of Patient 8s clinical notes, MD1 stated he did not have any notes for Patient 8. During a concurrent interview and record review on 5/3/2024 at 11:23 a.m. with Medical Director 2 (MD2) of Patient 8s clinical notes, MD2 stated he did not have any records for Patient 8. MD2 stated he did not see Patient 8. During a concurrent interview and record review on 5/2/2024, at 2:14 p.m., with DD of Patient 8s EMR, DD stated Patient 8 did not have SC or MSW notes in her EMR. 5. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an interview at the home visit on 4/20/2024, at 9:55 a.m. Registered Nurse 1 (RN 1) stated Patient 9 had heart failure, diabetes (elevated levels of sugar in the blood), and high blood pressure. During an interview at the home visit on 4/20/2024, at 10:10 a.m., RN 1 stated the goal of the visit was to assess for pain. During the visit, RN did not assess Patient 9s blood sugar levels and did not assess Patient 9 for symptoms of high (hyperglycemia) or low (hypoglycemia) blood sugar. During a concurrent observation and interview during the home visit on 4/30/2024, at 10:21 a.m., RN 1 assessed Patient 9s upper chest. RN 1 stated there was a dry, white dressing on the upper right chest wall, with two ports coming out of the dressing. Patient 9s caregiver (CG 1) stated it was her access port for her dialysis (a clinical purification of blood, as a substitute for the normal function of the kidneys) treatment every Monday and Friday. During an interview at the home visit on 4/20/2024, at 10:40 a.m., CG 1 stated Patient 9s medication ";Januvia" was for her diabetes. During an interview on 5/2/2024, at 11:04 a.m., Medical Director 1 (MD 1) stated he was aware Patient 9 had diabetes. MD 1 stated he was expecting for the nursing staff to assess Patient 9s diabetes to make sure she was not getting hyperglycemic or hypoglycemic. MD 1 stated the nursing staff should report to him if there is anything unusual such as having hyper/hypo glycemia. MD 1 stated patients with diabetes should be monitored at least once a week. During a concurrent interview and record review on 5/2/2024, at 11:14 a.m., DD reviewed Patient 9s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 3/27/2024. DD reviewed section ";Endocrine" and stated the record indicated ";WNL" (within normal limits). DD stated the record should have had a narrative about diabetes to include blood sugar levels. DD stated the assessment focused on the heart failure. DD stated diabetes did have an effect on heart failure and should have been assessed. DD stated the system assessment was important because that is what was used to formulate the plan of care for the patient. A record review of Patient 9s document titled, ";Initial Orders and Plan of Care", dated 3/27/2024, did not indicate a plan of care was formulated. During an interview on 4/30/2024 at 12:55 p.m. with the Director of Nurses Designee (DD), DD stated the HA ";tries" to conduct the initial interdisciplinary team meetings during the admission process and no later than the following day. DD stated MSW and SC services are offered on admission and are send out despite the patient and/or family/care giver refusal. DD stated the HAs RN, office staff, the assigned visiting nurse, MSW, SC, and physician are called to verify patients medications, ancillaries, and durable medical equipment (DME). DD stated all disciplines have individualized access to log into the HAs EMR system. DD stated all disciplines were to log into the HAs EMR system to document their concerns and sign in their attendance. During an interview on 4/30/2024 at 2:40 p.m. with DD, DD stated the HA offers SC and MSW services to patients and their families/care givers on admission and monthly. DD stated that if patients and/or families/care givers refused either service, the discipline would document their refusal in the IDT meeting notes. DD stated SC and MSW services were part of the HAs core services offered to patients. During an interview on 5/2/2024 at 11:25 a.m. with DD, DD stated a patient comprehensive assessment is a head-to-toe assessment which is used to initiate patients individualized plan of care which indicate their goals and interventions. A record review of the HAs policy and procedure titled, ";Comprehensive Assessment", dated April 2020, indicated, ";A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. Procedure: 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least the following information, as relevant: ...G. A physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patients terminal illness...S. The patients psychosocial status...T. An assessment of the patients and family/caregivers spiritual orientation...". A record review of the HAs policy and procedure titled, ";Initial Assessment", dated April 2020, indicated, ";Policy: An initial assessment will be performed by a registered nurse within 48 hours after election of hospice...6. Admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during this initial assessment....7. Based on the initial assessment, the plan of care will be initiated on the day of admission. 8. The initial assessment will be filed in the patients clinical record." A record review of the HAs policy and procedure titled, ";Spiritual Assessment", dated April 2020, indicated, ";Procedure: 1. On admission, the hospice registered nurse will conduct an initial spiritual assessment. 2. The Hospice Chaplain will contact the patient/family by a home visit or by telephone based on the patients and familys needs and acceptance of these services." A record review of the HAs policy and procedure titled, ";Psychosocial Assessment", dated April 2020, indicated, ";Policy: A thorough psychosocial assessment will be initiated at the time of admission and continued throughout the course of care. Psychosocial assessment will be completed by a qualified hospice social worker or hospice registered nurse." .

Based on observation, interview, and record review, the Hospice Agency (HA) staff failed to review all medications two of fourteen sampled patients (Patient 4 and Patient 9) were taking and update their medication profiles with the currently used medications. This failure had the potential to place patients were at risk for medication errors and adverse drug reactions. --- 1. During a review of Patient 4s record titled, ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form titled, ";Patient Medication Profile" dated 3/1/2024 – 5/29/2024, indicated none of the medications had their indications listed. The form also indicated Furosemide (medication to remove excess water), did not have its classification listed. Lastly, the form indicated Patient 4 was prescribed ";Levothyroxine (thyroid medication)". During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 4s home, LVN2 did not reconciliate Patient 4s medications. LVN2 stated she did not have Patient 4s HAs medication list and did not see it in his Electronic Medical Record (EMR). LVN2 stated she has not reconciled Patient 4s medication. During a review of Patient 4s home medication, Levothyroxine was not provided by Caretaker 1 (CT1). CT1 reminded LVN2 to order Patient 4s thyroid medication. CT1 stated Patient 4 also takes Lipitor (high cholesterol medication) and needs his diabetic medication. LVN2 stated she was not aware Patient 4 was a diabetic patient. During an interview on 4/30/2024 at 12:55 p.m. with the Director of Nurse Designee (DD), DD stated patients and their families/caregivers are provided with their medication list during the initial nursing visit to be used as a reference. DD stated medication reconciliation should be done during every skill nursing visits to ensure it is current. DD stated the skilled nurse compares the medications to the patients medication profile to look for changes. DD state patient medication list is updated when there are changes. 2. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During a concurrent observation, interview, and record review, on 4/30/2024, at 10:30 a.m., Registered Nurse 1 (RN 1) reviewed medications Patient 9 was taking at home, using record titled, ";Patient Medication Profile", accessed through his phone, for election period 3/27/2024-6/24/2024." RN 1 interviewed Patient 9s caregiver (CG1) who stated medication ";Hydralazine (for blood pressure) was given to Patient 9 only when her systolic blood pressure was greater than 140. RN 1 stated the label for Hydralazine indicated to take 3 times daily. The medication profile indicated to take 1 tablet daily. The medication profile did not have the blood pressure parameters as stated by CG 1. Continued review of the medications by RN 1 indicated the following: Medication ";losartan" (for blood pressure) was listed, and CG 1 stated Patient 9 was no longer taking. The medication profile had the wrong frequency listed for medication ";Carafate". The medication profile indicated ";Carafate" (for stomach ulcer) tablet 1 gram (unit of measurement) 1 tablet once before breakfast. RN 1 stated the label indicated to take twice daily, before breakfast and before dinner. The medication profile had the wrong dose listed for medication ";Cardizem LA" (for high blood pressure and chest pain). RN 1 stated the medication profiled indicated to take 180 mg (milligrams, unit of measurement) tablet daily. The label indicated to take 2 capsules once daily. RN 1 stated medication ";Docusate Sodium" (stool softener) was at the patients home, but not listed in the medication profile. During an interview on 4/30/2024, at 10:49 a.m., RN 1 stated medications were supposed to be reviewed every visit. The importance included to, check for expiration, know all the medications the patient is taking, to monitor side effects, to monitor any changes in medication, and to make sure the medications are working. A review of the HAs policy and procedure titled, ";Contents of Clinical Record", dated April 2020, indicated, ";Procedure: 1. The following information will be available in the clinical record as applicable to care and services provided...J. Current medication profile including: prescription and nonprescription medications, herbal products, and home remedies: dose frequency, and route of administration; with ongoing updates to the patients medication regimen, including new, changed, and discontinued medications..." 1. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form titled ";Patient Medication Profile" dated 3/1/2024 – 5/29/2024, indicated none of the medications had their indications listed. The form also indicated Furosemide (medication to remove excess water), did not have its classification listed. Lastly, the form indicated Patient 4 was prescribed ";Levothyroxine (thyroid medication)". During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 4s home, LVN2 did not reconciliate Patient 4s medications. LVN2 stated she did not have Patient 4s HAs medication list and did not see it in his Electronic Medical Record (EMR). LVN2 stated she has not reconciled Patient 4s medication. During a review of Patient 4s home medication, Levothyroxine was not provided by Caretaker 1 (CT1). CT1 reminded LVN2 to order Patient 4s thyroid medication. CT1 stated Patient 4 also takes Lipitor (high cholesterol medication) and needs his diabetic medication. LVN2 stated she was not aware Patient 4 was a diabetic patient. During an interview on 4/30/2024 at 12:55 p.m. with the Director of Nurse Designee (DD), DD stated patients and their families/caregivers are provided with their medication list during the initial nursing visit to be used as a reference. DD stated medication reconciliation should be done during every skill nursing visits to ensure it is current. DD stated the skilled nurse compares the medications to the patients medication profile to look for changes. DD state patient medication list is updated when there are changes. 2. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During a concurrent observation, interview, and record review, on 4/30/2024, at 10:30 a.m., Registered Nurse 1 (RN 1) reviewed medications Patient 9 was taking at home, using record titled, ";Patient Medication Profile", accessed through his phone, for election period 3/27/2024-6/24/2024." RN 1 interviewed Patient 9s caregiver (CG1) who stated medication ";Hydralazine (for blood pressure) was given to Patient 9 only when her systolic blood pressure was greater than 140. RN 1 stated the label for Hydralazine indicated to take 3 times daily. The medication profile indicated to take 1 tablet daily. The medication profile did not have the blood pressure parameters as stated by CG 1. Continued review of the medications by RN 1 indicated the following: Medication ";losartan" (for blood pressure) was listed, and CG 1 stated Patient 9 was no longer taking. The medication profile had the wrong frequency listed for medication ";Carafate". The medication profile indicated ";Carafate" (for stomach ulcer) tablet 1 gram (unit of measurement) 1 tablet once before breakfast. RN 1 stated the label indicated to take twice daily, before breakfast and before dinner. The medication profile had the wrong dose listed for medication ";Cardizem LA" (for high blood pressure and chest pain). RN 1 stated the medication profiled indicated to take 180 mg (milligrams, unit of measurement) tablet daily. The label indicated to take 2 capsules once daily. RN 1 stated medication ";Docusate Sodium" (stool softener) was at the patients home, but not listed in the medication profile. During an interview on 4/30/2024, at 10:49 a.m., RN 1 stated medications were supposed to be reviewed every visit. The importance included to, check for expiration, know all the medications the patient is taking, to monitor side effects, to monitor any changes in medication, and to make sure the medications are working. A review of the HAs policy and procedure titled, ";Contents of Clinical Record", dated April 2020, indicated, ";Procedure: 1. The following information will be available in the clinical record as applicable to care and services provided...J. Current medication profile including: prescription and nonprescription medications, herbal products, and home remedies: dose frequency, and route of administration; with ongoing updates to the patients medication regimen, including new, changed, and discontinued medications..."

Based on interview and record review, the Hospice Agency (HA) failed to ensure seven of fourteen sampled patients (Patient 2, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, and Patient 11) received an initial bereavement assessment. This failure had the potential to result in placing the patients and their family/caregiver at risk of spiritual and emotional distress. --- 1. During a review of Patient 2s medical record form titled, ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 2s medical record form titled, ";Initial Orders and Plan of Care" dated 1/5/2024, indicated Patient 2 declined social worker and spiritual care visits. The form also indicated it was not signed by HAs Medical Social Worker (MSW), Spiritual Counselor (SC), or Physician. During a review of Patient 2s medical record form titled, ";Date Initial Nursing Assessment Initiated 1/5/2024" indicated ";Psychosocial Status – Bereavement Risk Factor – Lack of support system; Role changes; Financial Issues". The form also indicated ";Spiritual Assessment – Informed hospice Chaplain to contact in... Evaluation of Bereavement Risk: Low". Lastly, the form indicated ";Coordination of Care – Collaboration with - MSW; Chaplain". During a review of Patient 2s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 1/5/2024, indicated ";Spiritual Care Report – Chaplain visits – Initial assessment within 5 days to provide spiritual support to patient and family. / SW Report – MSW visits initial assessment within 5 days to provide psychosocial support to patient and family". The form also indicated it was not singed by any HA staff. During a concurrent interview and record review on 5/2/2024 at 2:14 p.m. with the Director of Nurse Designee (DD) of Patient 2s Electronic Medical Record (EMR), DD stated Patient 2 does not have any documentation entered by the MSW or SC. DD stated Patient 2s EMR does not indicate there was an initial bereavement documented. 2. During a review of Patient 4s record titled, ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form titled, ";Date Initial Nursing Assessment Initiated 3/1/2024" indicated ";Psychosocial Status – Bereavement Risk Factor – Recent diagnosis; Role changes". The form also indicated ";Spiritual Assessment –Church/Synagogue: NONE; Evaluation of Bereavement Risk: Low". Lastly, the form indicated ";Coordination of Care – Collaboration with:" did not include the MSW or SC. During a review of Patient 4s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated ";Spiritual Care Report – Offered and declined. Well try to offer in 2 weeks. / SW Report – Offered and declined. Well try to offer in 2 weeks.". The form also indicated it was not singed by any HA staff. During a review of Patient 4s medical record form titled, ";Physician Order Details" dated 3/1/2024, indicated ";MSW- services offered but declined. Will continue to be offered. / Chaplain visits - services offered but declined. Will continue to be offered." During a concurrent interview and record review on 5/2/2024 at 2:14 p.m. with the Director of Nurse Designee (DD) of Patient 4s Electronic Medical Record (EMR), DD stated Patient 4 does not have any documentation entered by the MSW or SC. DD stated Patient 4s EMR does not indicate there was an initial bereavement documented. 3. A review of Patient 5s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/7/2024" with a hospice diagnosis of end stage heart failure (heart unable to pump adequately, shortness of breath, fatigue, and irregular heartbeat even while at rest). The form also indicated ";Psychosocial Status – Bereavement Risk Factor – Financial Issues". The form also indicated ";Spiritual Assessment –Church/Synagogue: Christina; Evaluation of Bereavement Risk: Low". Lastly, the form indicated ";Coordination of Care – Collaboration with - MSW; Chaplain". During a concurrent interview and record review on 5/2/2024 at 2:14 p.m. with the Director of Nurse Designee (DD) of Patient 5s Electronic Medical Record (EMR), DD stated Patient 5 does not have any documentation entered by the MSW or SC. DD stated Patient 5s EMR does not indicate there was an initial bereavement documented. 4. A review of Patient 6s medical record form titled, ";Initial Orders and Plan of Care", indicated a start of care date on 1/22/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 6s medical record form titled, ";Initial Orders and Plan of Care" dated 1/22/2024, indicated Patient 6 declined social worker and spiritual care visits. The form also indicated it was not signed by HAs Registered Nurse (RN), Medical Social Worker (MSW), Spiritual Counselor (SC), or Physician. During a review of Patient 6s medical record form titled, ";Date Initial Nursing Assessment Initiated 1/22 /2024" indicated ";Psychosocial Status – Bereavement Risk Factor" was left blank. The form also indicated ";Evaluation of Bereavement Risk: Low". Lastly, the form indicated the MSW and SC were not selected under section ";Coordination of Care – Collaboration with:". During a review of Patient 6s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 1/22/2024, indicated ";Spiritual Care Report – Chaplain visits – Initial assessment within 5 days to provide spiritual support to patient and family. / SW Report – MSW visits initial assessment within 5 days to provide psychosocial support to patient and family". The form also indicated it was not singed by any HA staff. During a concurrent interview and record review on 5/2/2024 at 2:14 p.m. with the Director of Nurse Designee (DD) of Patient 6s Electronic Medical Record (EMR), DD stated Patient 6 does not have any documentation entered by the MSW or SC. DD stated Patient 6s EMR does not indicate there was an initial bereavement documented. 5. A review of Patient 7s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/9/2024" with a hospice diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). The form also indicated ";Psychosocial Status – Bereavement Risk Factor" was left blank. The form also indicated ";Evaluation of Bereavement Risk: Low". Lastly, the form indicated there were no disciplines selected under section ";Coordination of Care – Collaboration with:". During a review of Patient 7s medical record form titled, ";Initial Orders and Plan of Care" dated 1/9/2024, indicated Patient 7 declined social worker and spiritual care visits. The form also indicated it was not signed by HAs Medical Social Worker (MSW), Spiritual Counselor (SC), or Physician During a review of Patient 7s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 1/9/2024, indicated ";Spiritual Care Report – Chaplain visits – Initial assessment within 5 days to provide spiritual support to patient and family. / SW Report – MSW visits initial assessment within 5 days to provide psychosocial support to patient and family". The form also indicated it was not singed by MSW, SC, or physician. During a concurrent interview and record review on 5/2/2024 at 2:14 p.m. with the Director of Nurse Designee (DD) of Patient 7s Electronic Medical Record (EMR), DD stated Patient 7 does not have any documentation entered by the MSW or SC. DD stated Patient 7s EMR does not indicate there was an initial bereavement documented. 6. A review of Patient 8s record titled, ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 8s medical record form titled ";Date Initial Nursing Assessment Initiated 4/25/2024" indicated ";Psychosocial Status – Bereavement Risk Factor; Spiritual Assessment; Evaluation of Bereavement Risk; Coordination of Care – Collaboration with:" were left blank. During a review of Patient 8s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/26/2024, indicated ";Spiritual Care Report – Chaplain visits – Initial assessment within 5 days to provide spiritual support to patient and family. / SW Report – MSW visits initial assessment within 5 days to provide psychosocial support to patient and family". The form also indicated it was not singed by any HA staff. During a concurrent interview and record review on 5/2/2024 at 2:14 p.m. with the Director of Nurse Designee (DD) of Patient 8s Electronic Medical Record (EMR), DD stated Patient 8 does not have any documentation entered by the MSW or SC. DD stated Patient 8s EMR does not indicate there was an initial bereavement documented. 7. A review of Patient 11s record titled, ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 11s medical record form titled ";Initial Orders and Plan of Care" dated 2/27/2024, indicated form was left blank. The form also indicated it was not signed by any HAs staff. During a review of Patient 11s medical record form titled, ";Date Initial Nursing Assessment Initiated 2/27/2024" indicated ";Psychosocial Status – Bereavement Risk Factor – none". The form also indicated ";Spiritual Assessment – Refuses contact; Evaluation of Bereavement Risk: Low". Lastly, the form indicated the MSW and SC were not selected under section ";Coordination of Care – Collaboration with:". During a review of Patient 11s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated ";Spiritual Care Report – Declined services. Patient will be contacted in 3 weeks. / SW Report – Declined services. Patient will be contacted in 2 weeks.". The form also indicated it was not singed by any HA staff. During a review of Patient 11s medical record form titled, ";Physician Order Details" dated 4/18/2024, indicated ";MSW- services offered but declined. Will continue to be offered. / Chaplain visits - services offered but declined. Will continue to be offered." During a concurrent interview and record review on 5/2/2024 at 2:14 p.m. with the Director of Nurse Designee (DD) of Patient 11s Electronic Medical Record (EMR), DD stated Patient 11 does not have any documentation entered by the MSW or SC. DD stated Patient 11s EMR does not indicate there was an initial bereavement documented. During an interview on 4/30/2024 at 12:55 p.m. with the Director of Nurse Designee (DD), DD stated bereavement services begin at time of admission. DD stated bereavement services include the same as counseling the family with the concept of dying and acceptance. Its spiritual, emotional, psychosocial counseling. DD stated bereavement services are offered for 13 months after a patient passes away. During an interview on 4/30/2024 at 2:40 p.m. with the Director of Nurse Designee (DD), DD stated that if there was nothing documented by the MSW or SC, it was because the patient and/or family decline their services. DD stated the MSW or SC will document the declination of services in the patients IDT meetings. DD stated that if a patient declines, the HA will continue to offer MSW and SC services monthly. DD stated MSW and SC services are part of the hospice core services, which should be offered monthly to patients. A record review of the HAs policy and procedure titled, ";Comprehensive Assessment", dated April 2020, indicated, ";Procedure: 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least the following information, as relevant:...W. A bereavement assessment of the needs of the patients family and other individuals focusing on: 1. The nature of the relationship to the patient. 2. Circumstances surrounding the illness/prognosis. 3. Behaviors prior to and after the illness/prognosis. 4. Survivor needs (social, spiritual, and cultural) that ay impact coping skills. 5. Potential for pathological grief reactions". A record review of the HAs policy and procedure titled, ";Bereavement Services", dated April 2020, indicated, ";Procedure: 1. A bereavement risk assessment will be completed by the hospice social worker at the tie of admission to hospice."

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 4, Patient 9, Patient 10, Patient 11, and Patient 12). This failure resulted in patients not being properly evaluated which resulted in not being provided individualized focused care. --- 1. A review of Patient 1s record titled, ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During an interview on 4/30/2024, at 1:09 p.m., DD stated the IDG group documented the meeting in the electronic medical record (EMR) right away. Each discipline had their own computer access, and each discipline entered their own note in the EMR. DD stated the IDG group, composed of the RN, MSW, Chaplain, and doctor, met every two weeks. A record review of Patient 1s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/5/2024, did not have any entries/narratives documented for the doctor, RN, MSW, and chaplain report. Further review of the record indicated names of the RN, doctor, Medical Social Worker 1 (MSW 1), Medical Social Worker 2 (MSW 2) and Chaplain. However, there was no signatures in the document. A record review of Patient 1s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/19/2024, did not have any entries/narratives documented for the doctor, RN, MSW, and chaplain report. Further review of the record indicated names of the RN, doctor, MSW 1, MSW 2, and Chaplain. However, there was no signatures in the document. 2. During a review of Patient 2s medical record form titled, ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 2s medical record form titled, ";Date Initial Nursing Assessment Initiated 1/5/2024" indicated ";Need for comprehensive assessment – social work; spiritual care; dietician; physician; occupational therapist." The form also indicated ";Summary/Plan/Support Diagnosis: ... IDT notified of admission...". Lastly, the form indicated it was not signed by HA staff. During a review of Patient 2s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 1/5/2024, indicated ";Spiritual Care Report – Chaplain visits – Initial assessment within 5 days to provide spiritual support to patient and family. / SW Report – MSW visits initial assessment within 5 days to provide psychosocial support to patient and family". The form also indicated ";Physician Report" section was left blank. Lastly, the form also indicated it was not singed by any HA staff. During a review of Patient 2s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated ";Physician Report, Spiritual Care Report and SW Report" were left blank. The form also indicated it was not signed by any HA staff. During a review of Patient 2s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated ";Physician Report, Spiritual Care Report and SW Report" were left blank. The form also indicated it was not signed by any HA staff. During a review of Patient 2s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated ";Physician Report, Spiritual Care Report and SW Report" were left blank. The form also indicated it was not signed by any HA staff. 3. During a review of Patient 4s record titled, ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form titled, ";Date Initial Nursing Assessment Initiated 3/1/2024" indicated ";Need for comprehensive assessment – spiritual care; bereavement." The form also indicated it was not signed by HA staff. During a review of Patient 4s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated ";Spiritual Care Report – Offered and declined. Well try to offer in 2 weeks. / SW Report – Offered and declined. Well try to offer in 2 weeks.". The form also indicated ";Physician Report" section was left blank. Lastly, the form also indicated it was not signed by any HA staff. During a review of Patient 4s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated ";Spiritual Care Report – Offered and declined. Well try to offer in 2 weeks. / SW Report – Offered and declined. Well try to offer in 2 weeks.". The form also indicated ";Physician Report" section was left blank. Lastly, the form also indicated it was not signed by any HA staff. During a review of Patient 4s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated ";Spiritual Care Report, SW Report and Physician Report" sections were left blank. Lastly, the form also indicated it was not signed by any HA staff. 4. A review of Patient 9s record titled, ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an interview at the home visit on 4/30/2024, at 10:10 a.m., RN 1 stated the goal of the visit was to assess for pain. During the visit, RN did not assess Patient 9s blood sugar levels and did not assess Patient 9 for symptoms of high (hyperglycemia) or low (hypoglycemia) blood sugar. During a concurrent observation and interview during the home visit on 4/30/2024, at 10:21 a.m., RN 1 assessed Patient 9s upper chest. RN 1 stated there was a dry, white dressing on the upper right chest wall, with two ports coming out of the dressing. Patient 9s caregiver (CG 1) stated it was her access port for her dialysis (a clinical purification of blood, as a substitute for the normal function of the kidneys) treatment every Monday and Friday. During an interview at the home visit on 4/30/2024, at 10:40 a.m., CG 1 stated Patient 9s medication ";Januvia" was for her diabetes. During an interview on 5/2/2024, at 11:04 a.m., Medical Director 1 (MD 1) stated he was aware Patient 9 had diabetes. MD 1 stated he was expecting for the nursing staff to assess Patient 9s diabetes to make sure she was not getting hyperglycemic or hypoglycemic. MD 1 stated the nursing staff should report to him if there is anything unusual such as having hyper/hypo glycemia. MD 1 stated patients with diabetes should be monitored at least once a week. During a concurrent interview and record review on 5/2/2024, at 11:14 a.m., DD reviewed Patient 9s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 3/27/2024. DD reviewed section ";Endocrine" and stated the record indicated ";WNL" (within normal limits). DD stated the record should have had a narrative about diabetes to include blood sugar levels. DD stated the assessment focused on the heart failure. DD stated diabetes did have an effect on heart failure and should have been assessed. DD stated the system assessment was important because that is what was used to formulate the plan of care for the patient. A record review of Patient 9s document titled, ";Initial Orders and Plan of Care", dated 3/27/2024, did not indicate a plan of care was formulated. A record review of Patient 9s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/5/2024. The record indicated, Spiritual Care Report: ";IDT 4/5/2024, Chaplain visits-Initial assessment within 5 days to provide support to patient and family. SW Report IDT 4/5/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family. A record review of Patient 9s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/19/2024, indicated, ";IDT 4/19/2024, Chaplain visits-Initial assessment within 5 days to provide support to patient and family. SW Report IDT 4/19/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family. The record did not indicate the IDG team addressed Patient 9s diabetes, dialysis, and dialysis port status. Further review of the record indicated names of the IDG members. However, there were no signatures. 5. A review of Patient 10s record titled, ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A record review of Patient 10s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 1/2/2024, indicated, ";Spiritual Care Report: IDT 1/2/2024, Chaplain visits-Initial assessment within 5 days to provide support to patient and family. SW Report IDT 1/2/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family." A record review of Patient 10s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", for dates: 1/26/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 2/9/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 2/23/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 3/8/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 3/22/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 6. A review of Patient 11s record titled, ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 11s medical record form titled, ";Initial Orders and Plan of Care" dated 2/27/2024, indicated form was left blank. The form also indicated it was not signed by any HAs staff. During a review of Patient 11s medical record form titled, ";Date Initial Nursing Assessment Initiated 2/27/2024" indicated section ";Need for comprehensive assessment – Patient/caregiver refuses the following services and assessments: HA, SW, SC, Volunteer." The form also indicated it was not signed by HA staff. During a review of Patient 11s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated ";Spiritual Care Report – Declined services. Patient will be contacted in 3 weeks. / SW Report – Declined services. Patient will be contacted in 2 weeks.". The form also indicated ";Physician Report" section was left blank. Lastly, the form also indicated it was not singed by any HA staff. During a review of Patient 11s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated ";Spiritual Care Report – Declined services. Patient will be contacted in 2 weeks. / SW Report – Declined services. Patient will be contacted in 1 weeks.". The form also indicated ";Physician Report" section was left blank. Lastly, the form also indicated it was not signed by any HA staff. During a review of Patient 11s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated ";Spiritual Care Report – IDT 4/5/2024: D... (see addendum pages) / SW Report – IDT 4/5/2024: D... (see addendum pages)". The form also indicated ";Physician Report" section was left blank. Lastly, the form also indicated it was not signed by any HA staff. During a review of Patient 11s medical record form titled, ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/19/2024, indicated ";Spiritual Care Report – IDT 4/19/2024: ... (see addendum pages) / SW Report – IDT 4/19/2024: ... (see addendum pages)". The form also indicated ";Physician Report" section was left blank. Lastly, the form also indicated it was not signed by any HA staff. 7. A review of Patient 12s record titled, ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease). A record review of Patient 12s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", for dates: 1/12/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 1/26/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 2/9/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 2/23/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 3/22/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. During an interview on 4/30/2024 at 12:55 p.m. with the Director of Nurses Designee (DD), DD stated the IDT meetings are conducted during admission and no later than the following day and then every two weeks. DD stated the Registered Nurse (RN), office staff, Medical Social Worker (MSW), Spiritual Counselor (SC), and the doctor are called after the initial nursing assessment to verify patients medications, ancillaries, and DME (durable medical equipment: bed, oxygen, diapers, etc.). DD stated all disciplines have access with their personal log in information for the HAs Electronic Medical Record (EMR) system where they need to document their concerns and sign. A review of the HAs policy and procedure titled, ";Comprehensive Assessment", dated April 2020, indicated, ";Procedure...5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum every 15 days."

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 meet the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Interdisciplinary group, care planning, and coordination of services as follows: --- The HA failed to ensure to develop a Plan of Care (POC, maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patient's family/caregiver) for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) based on identified initial and updated assessments to address the management of health status of the patients. The deficient practice resulted in Patient 4 and Patient 9 were not being monitored for signs and symptoms of hypoglycemia or hyperglycemia crisis that could lead to serious harm, hospitalization and/or death. For Patient 1, Patient 2, Patient 3, Patient 8, Patient 10, Patient 11, and Patient 12 received hospice services without a written plan of care including management of terminal illness. (Refer to L545). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily (written law) mandated compliance with Federal regulations for Interdisciplinary group, care planning, and coordination of services. .

Based on observation, interview, and record review the Hospice Agency (HA) failed to follow the Plan of Care (POC) for two of fourteen sampled patients (Patient 1 and Patient 9), the HA did not provide skilled nurse visits as ordered by the physician. This deficient practice had the potential for delayed care and services to meet the patient care goals needs. --- 1. During a review of Patient 1s ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During a review of Patient 1s ";Date Initial Nursing Assessment Initiated 1/5/2024" indicated, ";Orders for Discipline and Treatments – SN visit", nothing was documented. During a review on 4/29/2024 at 5:48 p.m. of Patient 1s Electronic Medical Record (EMR), the EMR indicated the skilled visit note dated 4/7/2024 was left blank. During an interview on 4/30/2024 at 12:55 p.m. with the Director of Nurses Designee (DD), DD stated nurse visit notes should be completed and, in the Patient 1's EMR within 7 days of the home visit. DD stated if there were no nurse visit notes in their EMR system, then ";maybe" the skilled nurse did not visit the patient. 2. During a review of Patient 9s ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During a review of Patient 9s EMR on 4/29/2024, at 1:25 p.m., Patient 9's EMR has no nursing notes. During an interview at the home visit on 4/30/2024, at 9:55 a.m. with Registered Nurse 1 (RN 1), RN 1 stated, Patient 9 had heart failure, diabetes (elevated levels of sugar in the blood), and high blood pressure. RN 1 stated he visited Patient 9 weekly. During a concurrent interview and record review on 4/30/2024, at 9:59 a.m., with RN 1, RN 1 reviewed Patient 9s record titled, ";Initial Orders and Plan of Care", for certification period 3/27/2024 to 6/24/2024. RN 1 stated the Patient 9's "Initial Orders and Plan of Care" did not have any interventions and goals written on it. During an interview at the home visit on 4/30/2024, at 10:10 a.m., with RN 1 at Patient 9's home, RN 1 stated that the goal of the home visit to Patient 9 was to assess for pain. During the visit, RN 1 did not assess Patient 9s blood sugar levels and did not assess Patient 9 for symptoms of high (hyperglycemia) or low (hypoglycemia) blood sugar. During a concurrent observation and interview during the home visit on 4/30/2024, at 10:21 a.m., with RN 1 at Patient 9's home, RN 1 assessed Patient 9s upper chest. RN 1 stated there was a dry, white dressing on the upper right chest wall, with two ports coming out of the dressing. Patient 9s caregiver (CG 1) stated it was her access port for her dialysis (a clinical purification of blood, as a substitute for the normal function of the kidneys) treatment every Monday and Friday. During an interview at the home visit on 4/30/2024, at 10:40 a.m., with Caregiver 1 (CG 1), CG 1 stated, Patient 9s medication ";Januvia" was for her diabetes. During an interview and record review on 4/30/2024, at 10:45 a.m., Patient 9s second caregiver (CG 2) stated she wrote all the visits Patient 9 has received in a notebook. The notebook indicated Patient 9 received visits from the HA on 3/27/2024, 4/10/2024, 4/13/2024, and 4/30/2024. CG 2 stated nursing visits were every 2 weeks. CG 2 stated she did not remember a social worker or chaplain coming to the home or talking on the phone with them. During an interview on 4/30/2024, DD stated the nurses were called on 4/29/2024 and instructed to input their nursing notes in the EMR. DD stated anytime there is a survey, the nurses complete their notes, it shouldnt be that way, but it is. DD provided to the survey team nursing notes titled, ";Nursing Reassessment note", dated 3/27/24, 3/31/2024, 4/10/2024, 4/17/2024, and 4/24/2024. During an interview on 5/2/2024, at 11:04 a.m., Medical Director 1 (MD 1) stated he was aware Patient 9 had diabetes. MD 1 stated he was expecting for the nursing staff to assess Patient 9s diabetes to make sure she was not getting hyperglycemic or hypoglycemic. MD 1 stated the nursing staff should report to him if there is anything unusual such as having hyper/hypo glycemia. MD 1 stated patients with diabetes should be monitored at least once a week. A record review of Patient 9s document titled, ";Initial Orders and Plan of Care", dated 3/27/2024, did not indicate the services, frequency of visits, and interventions that were to be done every visit. A record review of the HAs policy and procedure titled, ";The Plan of Care", dated April 2020, indicated, ";Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program...The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The plan of care will include all necessary for the palliation and management of the terminal illness and related conditions. Procedures...4. It must state, in detail, the scope and frequency of services needed to meet the patients and family/caregivers needs, goals and outcome achievement. 5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care."

Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure to develop a plan of care (POC) for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) based on identified initial and updated assessments. For Patient 4 and Patient 9 who verbalized that they had diabetes and were taking medication for diabetes, and that were not being monitored for hypoglycemia (low blood sugar level) symptoms that included, fast heartbeat, shaking, sweating, confusion, and dizziness, or hyperglycemia (high blood sugar level) symptoms that included, weight loss, blurred vision, recurrent infections. For Patient 1, Patient 2, Patient 3, Patient 8, Patient 10, Patient 11, and Patient 12 received hospice services without a written plan of care for the management of current health status and symptoms of terminal illness. This deficient practice resulted in Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12, did not have POC for the current health status and for management of symptoms of terminal illness that is likely to cause delayed care, and undetected signs of physical, emotional, and spiritual needs when transitioning to the final stages of dying process. On 5/3/2024 at 11:47 a.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called in the presence of the agency's Director of Nurses Designee (DD), related to failure of HA to ensure to develop a plan of care (POC) for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) based on identified initial and updated assessments to address the management of health status of the patients. As a result, the non-compliance resulted in: Patient 4 and Patient 9 were not monitored for signs and symptoms of hypoglycemia or hyperglycemia that could lead to serious harm, hospitalization and/or death. Patient 1, Patient 3, Patient 4, Patient 8, Patient 10, Patient 11, and Patient 12 received hospice services without a written plan of care for the management of current health status and symptoms of terminal illness, that is likely to cause delayed care, and undetected signs of physical, emotional, and spiritual needs when transitioning to the final stages of dying process. On 5/4/2024 at 4 p.m., the survey team conducted an exit conference in the presence of DD, and the IJ was not removed. --- 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During a concurrent interview and record review on 5/2/2024, at 1:30 p.m., the Director of Patient Care Services designee (DD) reviewed Patient 1s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/5/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. During an interview on 5/2/2024, at 11:14 a.m., DD stated the comprehensive assessment was a system assessment that is used to formulate the plan of care for the patient. A record review of Patient 1s document titled, ";Initial Orders and Plan of Care", dated 1/5/2024, did not indicate a plan of care was formulated. 2. A review of Patient 2s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 2s home, Patient 2 was not at home. LVN2 stated she has not seen Patient 2 since March. LVN2 stated Patient 2s Caretaker 1 (CT1) informed her that Patient 2 had left the home on 4/16/2024. LVN2 stated she did not document anything regarding Patient 2s status in the HAs EMR system. LVN2 stated she did not know if the physician was aware of Patient 2s status. LVN2 stated Patient 2 did not have a plan of care and that she checked Patient 2s vital signs and environment. During a review of Patient 2s EMR, the EMR indicated there was one documented plan of care for Patient 2 dated 1/5/2024. Patient 2s EMR form titled ";IDT plan of care and review of comprehensive assessment" dated 1/5/2024, 3/8/2024, 3/22/2024, and 4/5/2024, indicated the following sections were left blank ";Hospice Physician; Co-morbid Diagnosis; Physician Report; Spiritual Care Report; SW Report; Volunteer Report; and Eligibility Assessment – Current Numbers." All forms did not indicate any HAs staff signatures. During a concurrent interview and record review on 5/2/2024 at 11:10 a.m. with Medical Director 1 (MD1) of Patient 2s clinical notes, MD1 stated he did not have any notes for Patient 2. MD1 stated he did not know anything about Patient 2. During a concurrent interview and record review on 5/3/2024 at 11:14 a.m. with Medical Director 2 (MD2) of Patient 2s clinical notes, MD2 stated he did not have any recollection of seeing Patient 2 or writing her notes. 3. A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). During a record review on 4/29/2024, at 1:20 p.m., Patient 3s record did not have a comprehensive assessment by the nurse. During a concurrent interview and record review on 5/2/2024, at 1:34 p.m., the DD reviewed Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/12/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. During an interview and record review on 5/4/2024, at 11:50 a.m., DD submitted Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 4/25/2024. DD stated she had given the surveyor the initial nursing assessment from another certification period. DD provided document titled, ";Document History", printed on 5/4/2024 and indicated the assessment record was created on 4/30/2024, day 2 of the survey. During an interview on 4/30/2024, at 1:19 p.m., the DD stated the registered nurse who saw the patient was supposed to initiate the POC. The POC needed to include goals, interventions, and frequency of visits. The POC was used to follow the care of the patient. A record review of Patient 3s document titled, ";Initial Orders and Plan of Care", dated 4/25/2024, did not indicate a plan of care was formulated. 4. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form untitled, indicated ";Initial Nursing Assessment Initiated 3/1/2024"; Certification period from 3/1/2024 to 5/29/2024. The following sections were left blank: POLST signed; Advance Directive; Allergies; and Co-morbidities Surgery dates. During a review on 4/29/2024 at 1:23 p.m. of Patient 4s Electronic Medical Record (EMR) medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated the form was left blank. The form also indicted the signature sections for Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) were left blank. During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 4s home, LVN2 stated she visits Patient 4 twice a week for wound dressing change. LVN2 stated she did not have Patient 4s individualized plan of care. LVN2 stated she provided Patient 4s care by following the admitting nurse verbal instructions. LVN2 stated her visits include changing Patient 4s head wound dressing, checking his vital signs, and checking the facility for safety. Patient 4 stated he had cholesterol, diabetes, and a wound on top of his head. LVN2 stated she was not aware Patient 4 had diabetes mellitus. During an interview on 5/1/2024 at 11:15 a.m. with Patient 4s Caretaker 1 (CT1), CT1 stated a Nurse Practitioner sees Patient 4 on Mondays. CT1 stated he has told and ask the Nurse Practitioner about Patient 4s diabetes medication and monitoring machine. CT1 stated Nurse Practitioner has told him that he will inform a doctor, but the doctor has not seen Patient 4. During a concurrent interview and record review on 5/2/2024 at 11:13 a.m. with Medical Director 1 (MD1) of Patient 4s clinical notes, MD1 stated he did not dictate any notes for Patient 4. During a concurrent interview and record review on 5/2/2024 at 1:35 p.m. with DD of Patient 4s EMR, DD stated Patient 4 did not have a plan of care. DD stated Patient 4 needed to have a plan of care. 5. A review of Patient 8s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 8s medical record form untitled, indicated ";Initial Nursing Assessment Initiated 4/25/2024" form indicated it was not complete. The following areas were not assessed vital signs to include blood pressure, temperature, pulse, respiratory rate; current weight; functional limitation, activities permitted, mental status, memory recall, skin, musculoskeletal, sensory, cardiovascular, gastrointestinal, pain assessment, respiratory, endocrine, nutrition/hydration, genitourinary, reproductive, additional assessment, activity of daily living, psychosocial assessment, spiritual assessment, skilled care/Services provided, coordination of care, equipment/supplies, plan of care, eligibility assessment, teaching, need for comprehensive assessment, attending physician, and summary/plan/support diagnosis. During a concurrent interview and record review on 4/30/2024 at 3:15 p.m. with the DD of Patient 8s EMR, DD stated Patient 8s start of care date was 4/25/2024. DD stated she was unable to locate an initial nursing assessment for Patient 8 that was supposed to be completed by 4/25/2024. DD stated Patient 8 did not have a documented plan of care. During a review of Patient 8s medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 4/26/2024, indicated there were no signatures in sections Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) were left blank. The form also indicated Medical Doctor 1 (MD1) and MD2s names were printed in section ";Physician Name, Signature, Date". During a concurrent interview and record review on 5/2/2024 at 10:48 a.m. with Medical Director 1 (MD1) of Patient 8s clinical notes, MD1 stated he did not have any notes for Patient 8. During a concurrent interview and record review on 5/3/2024 at 11:23 a.m. with Medical Director 2 (MD2) of Patient 8s clinical notes, MD2 stated he did not have any records for Patient 8. MD2 stated he did not see Patient 8. 6. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an interview at the home visit on 4/20/2024, at 9:55 a.m. Registered Nurse 1 (RN 1) stated Patient 9 had heart failure, diabetes (elevated levels of sugar in the blood), and high blood pressure. RN 1 stated he did not have a POC for the visit. RN 1 stated he had already read the POC prior to the visit and was familiar with it. During a concurrent interview and record review on 4/20/2024, at 9:59 a.m., RN 1 reviewed the surveyors Patient 9s record titled, ";Initial Orders and Plan of Care", for certification period 3/27/2024 to 6/24/2024. RN 1 stated the record did not have any interventions and goals written on it. During an interview at the home visit on 4/20/2024, at 10:10 a.m., RN 1 stated the goal of the visit was to assess for pain. During the visit, RN did not assess Patient 9s blood sugar levels and did not assess Patient 9 for symptoms of high (hyperglycemia) or low (hypoglycemia) blood sugar. During a concurrent observation and interview during the home visit on 4/30/2024, at 10:21 a.m., RN 1 assessed Patient 9s upper chest. RN 1 stated there was a dry, white dressing on the upper right chest wall, with two ports coming out of the dressing. Patient 9s caregiver (CG 1) stated it was her access port for her dialysis (a clinical purification of blood, as a substitute for the normal function of the kidneys) treatment every Monday and Friday. During an interview at the home visit on 4/20/2024, at 10:40 a.m., CG 1 stated Patient 9s medication ";Januvia" was for her diabetes. During an interview on 5/2/2024, at 11:04 a.m., Medical Director 1 (MD 1) stated he was aware Patient 9 had diabetes. MD 1 stated he was expecting for the nursing staff to assess Patient 9s diabetes to make sure she was not getting hyperglycemic or hypoglycemic. MD 1 stated the nursing staff should report to him if there is anything unusual such as having hyper/hypo glycemia. MD 1 stated patients with diabetes should be monitored at least once a week. MD 1 stated he was not aware Patient 9 did not have a POC. MD 1 stated the importance of having a POC was to follow standard regiment for each disease. Whoever is doing care, they can follow along and see what the progress is. MD 1 stated the risk of not having a POC is not knowing what is going on with the patient. That would be the whole purpose of the whole medical team, to know what is happening with the patient. During a concurrent interview and record review on 5/2/2024, at 11:14 a.m., DD reviewed Patient 9s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 3/27/2024. DD reviewed section ";Endocrine" and stated the record indicated ";WNL" (within normal limits). DD stated the record should have had a narrative about diabetes to include blood sugar levels. DD stated the assessment focused on the heart failure. DD stated diabetes did have an effect on heart failure and should have been assessed. DD stated the system assessment was important because that is what was used to formulate the plan of care for the patient. A record review of Patient 9s document titled, ";Initial Orders and Plan of Care", dated 3/27/2024, did not indicate a plan of care was formulated. 7. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A review of Patient 10s document titled, ";Initial Orders and Plan of Care", dated 1/2/2024, did not indicate a plan of care was formulated. 8. A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). A review of Patient 11s document titled, ";Initial Orders and Plan of Care", dated 2/27/2024, did not indicate a plan of care was formulated. During a concurrent interview and record review on 5/2/2024 at 11:16 a.m. with Medical Director 1 (MD1) of Patient 11s clinical notes, MD1 stated Patient 11 did not meet hospice criteria and did not admit her to hospice care. During a concurrent interview and record review on 5/3/2024 at 11:23 a.m. with Medical Director 2 (MD2) of Patient 11s clinical notes, MD2 stated he did not see Patient 11. 9. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). A review of Patient 12s document titled, ";Initial Orders and Plan of Care", dated 1/9/2024, did not indicate a plan of care was formulated. During an interview on 4/30/2024 at 12:55 p.m. with the DD, DD stated the Registered Nurse who initially assesses the patient initiates their plan of care. DD stated patients plan of care are based on their needed interventions to meet their goals. DD stated patients plan of care indicate their medications, disciplines with their frequencies, and their needed interventions. During an interview on 5/2/2024 at 10:48 a.m. with MD1, MD1 stated anyone who sees patients that do not have a plan of care will not know what is going on with the patient. MD1 stated that the whole purpose of the medical team was to be able to follow what is occurring with the patient. A record review of the HAs policy and procedure titled, ";Initial Assessment", dated April 2020, indicated, ";Policy: ...7. Based on the initial assessment, the plan of care will be initiated on the day of admission." A record review of the HAs policy and procedure titled, ";Hospice Nursing Care", dated April 2020, indicated, ";Procedure...2. The hospice nurse will participate in developing and implementing the plan of care and will report the condition of patient and family/caregiver to the attending physician, Medical Director, and interdisciplinary group on a regular basis, as well as changes in the plan of care". A record review of the HAs policy and procedure titled, ";The Plan of Care", dated April 2020, indicated, ";Policy: A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program...The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days. This plan will focus on identified problems, goals, and interventions. The plan of care will include all necessary for the palliation and management of the terminal illness and related conditions. Procedures...4. It must state, in detail, the scope and frequency of services needed to meet the patients and family/caregivers needs, goals and outcome achievement. 5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care." ..

Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) reviewed and revised the POC that reflected the current health status, for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 4, Patient 9, Patient 10, Patient 11, and Patient 12). This deficient practice resulted in patients not being evaluated which resulted in not being provided individualized focused care. --- 1. A review of Patient 1s ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During an interview on 4/30/2024, at 1:09 p.m., with DD, DD stated the IDG group documented the meeting in the electronic medical record (EMR) right away. Each discipline had their own computer access, and each discipline entered their own note in the EMR. DD stated the IDG group, composed of the RN, MSW, Chaplain, and doctor, met every two weeks. A record review of Patient 1s ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/5/2024, did not have any entries/narratives documented for the doctor, RN, MSW, and chaplain report. Further review of the record indicated names of the RN, doctor, Medical Social Worker 1 (MSW 1), Medical Social Worker 2 (MSW 2), and Chaplain. However, there were no signatures in the document. A record review of Patient 1s ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/19/2024, did not have any entries/narratives documented for the doctor, RN, MSW, and chaplain report. Further review of the record indicated names of the RN, doctor, MSW 1, MSW 2, and Chaplain. However, there were no signatures in the document. 2. During a review of Patient 2s ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 2s ";Date Initial Nursing Assessment Initiated 1/5/2024" indicated ";Need for comprehensive assessment – social work; spiritual care; dietician; physician; occupational therapist." The form also indicated ";Summary/Plan/Support Diagnosis: ... IDT notified of admission...". During a review of Patient 2s ";IDT plan of Care & Review of Comprehensive Assessment" dated 1/5/2024, indicated ";Physician Report" section was left blank. Lastly, the form also indicated it was not signed by any HA staff. During a review of Patient 2s ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated ";Physician Report, Spiritual Care Report and SW Report" were left blank. The form also indicated it was not signed by any HA staff. During a review of Patient 2s ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated ";Physician Report, Spiritual Care Report and SW Report" were left blank. The form also indicated it was not signed by any HA staff. During a review of Patient 2s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated ";Physician Report, Spiritual Care Report and SW Report" were left blank. The form also indicated it was not singed by any HA staff. 3. During a review of Patient 4s ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s ";Date Initial Nursing Assessment Initiated 3/1/2024" indicated ";Need for comprehensive assessment – spiritual care; bereavement." The form also indicated it was not signed by HA staff. During a review of Patient 4s ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated ";Physician Report" section was left blank. The form also indicated it was not signed by any HA staff. During a review of Patient 4s ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated ";Physician Report" section was left blank. The form also indicated it was not signed by any HA staff. During a review of Patient 4s ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated ";Spiritual Care Report, SW Report and Physician Report" sections were left blank. The form also indicated it was not signed by any HA staff. 4. A review of Patient 9s ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an interview at the home visit on 4/30/2024, at 10:10 a.m., with RN 1, RN1 stated the goal of the visit was to assess for pain. During the visit, RN did not assess Patient 9s blood sugar levels and did not assess Patient 9 for symptoms of high (hyperglycemia) or low (hypoglycemia) blood sugar. During a concurrent observation and interview during the home visit on 4/30/2024, at 10:21 a.m., with RN 1, RN 1 assessed Patient 9s upper chest. RN 1 stated there was a dry, white dressing on the upper right chest wall, with two ports coming out of the dressing. Patient 9s caregiver (CG 1) stated it was her access port for her dialysis (a clinical purification of blood, as a substitute for the normal function of the kidneys) treatment every Monday and Friday. During an interview at the home visit on 4/30/2024, at 10:40 a.m., CG 1 stated Patient 9s medication ";Januvia" was for her diabetes. During an interview and record review on 4/30/2024, at 10:45 a.m., Patient 9s second caregiver (CG 2) stated she wrote all the visits Patient 9 has received in a notebook. The notebook indicated Patient 9 received visits from the HA on 3/27/2024, 4/10/2024, 4/13/2024, and 4/30/2024. CG 2 stated she did not remember a social worker or chaplain coming to the home or talking on the phone with them. During an interview on 5/2/2024, at 11:04 a.m., Medical Director 1 (MD 1) stated he was aware Patient 9 had diabetes. MD 1 stated he was expecting for the nursing staff to assess Patient 9s diabetes to make sure she was not getting hyperglycemic or hypoglycemic. MD 1 stated the nursing staff should report to him if there is anything unusual such as having hyper/hypo glycemia. MD 1 stated patients with diabetes should be monitored at least once a week. During a concurrent interview and record review on 5/2/2024, at 11:14 a.m., with DD, DD reviewed Patient 9s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 3/27/2024. DD reviewed section ";Endocrine" and stated the record indicated ";WNL" (within normal limits). DD stated the record should have had a narrative about diabetes to include blood sugar levels. DD stated the assessment focused on the heart failure. DD stated diabetes did have an effect on heart failure and should have been assessed. DD stated the system assessment was important because that is what was used to formulate the plan of care for the patient. A record review of Patient 9s ";Initial Orders and Plan of Care", dated 3/27/2024, Patient 9 has no plan of care. A record review of Patient 9s ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/5/2024. The record indicated, Spiritual Care Report: ";IDT 4/5/2024, Chaplain visits-Initial assessment within 5 days to provide support to patient and family. SW Report IDT 4/5/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family. A record review of Patient 9s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/19/2024, indicated, ";IDT 4/19/2024, Chaplain visits-Initial assessment within 5 days to provide support to patient and family. SW Report IDT 4/19/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family. The record did not indicate the IDG team updated the plan of care to include Patient 9s diabetes, dialysis, and dialysis port status. Further review of the record indicated names of the IDG members. However, there were no signatures. 5. A review of Patient 10s ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A record review of Patient 10s ";IDT Plan of Care & Review of Comprehensive Assessment", dated 1/2/2024, indicated, ";Spiritual Care Report: IDT 1/2/2024, Chaplain visits-Initial assessment within 5 days to provide support to patient and family. SW Report IDT 1/2/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family." A record review of Patient 10s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", for dates: 1/26/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 2/9/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 2/23/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 3/8/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 3/22/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 6. A review of Patient 11s ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 11s ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated ";Physician Report" section was left blank. The form also indicated it was not signed by any HA staff. During a review of Patient 11s ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated ";Physician Report" section was left blank. The form also indicated it was not signed by any HA staff. During a review of Patient 11s ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated ";Physician Report" section was left blank. The form also indicated it was not signed by any HA staff. During a review of Patient 11s ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/19/2024, indicated ";Physician Report" section was left blank. The form also indicated it was not signed by any HA staff. 7. A review of Patient 12s ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease). A record review of Patient 12s ";IDT Plan of Care & Review of Comprehensive Assessment", for dates: 1/12/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 1/26/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 2/9/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 2/23/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 3/22/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. During an interview on 4/30/2024 at 12:55 p.m. with the Director of Nurses Designee (DD), DD stated the IDT meetings are conducted during admission and no later than the following day and then every two weeks. DD stated the Registered Nurse (RN), office staff, Medical Social Worker (MSW), Spiritual Counselor (SC), and the doctor are called after the initial nursing assessment to verify patients medications, ancillaries, and DME (durable medical equipment: bed, oxygen, diapers, etc.). DD stated all disciplines have access with their personal log in information for the HAs Electronic Medical Record (EMR) system where they need to document their concerns and sign. A review of the HAs policy and procedure titled, ";The Plan of Care", dated April 2020, indicated, ";Procedure...9.The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessments of the patient and family/caregiver. Review of the plan of care will be documented in the clinical record. Revision dates will be noted on the plan of care."

Based on interview and record review the Hospice Agency (HA) failed to ensure that the care and services were communicated with the hospice team to ensure services were provided as ordered for wo of fourteen sampled patients (Patient 2 and Patient 4). For Patient 2, the HA was aware that Patient 2 was not receiving hospice services for the past month. For Patient 4, the HA was not aware of Patient 4s current wound care assessment and management. This deficient practice resulted in Patient 2 and Patient 4, not receiving care and services to met their care goals needs. --- 1.During a review of Patient 2s ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 2s ";Date Initial Nursing Assessment Initiated 1/5/2024" indicated ";Orders for Discipline and Treatments – SN Visits 1st week: 1 visits, 1-2 PRN (as needed)". Section ";Following Weeks:" was left blank. The form also indicated ";Summary/Plan/Support Diagnosis: ... IDT notified of admission...". Lastly, the form indicated it was not signed by HA staff. During a joint home visit on 5/1/2024 at 11;15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 2s home, LVN2 stated last time she saw Patient 2 was in March 2024. LVN2 stated Patient 2s Caretaker 1 (CT1) informed her that Patient 2 had left the board and care facility on 4/16/2024 at which time she notified the HA. LVN2 stated she did not document in Patient 2s EMR about her not being at the board and care. CT1 stated Patient 2 was an alcoholic and was coming home inebriated. CT1 stated Patient 2 left the board and care sometime in March 2024. During a concurrent interview and record review on 5/2/2024 at 12:04 p.m. with the Director of Nurses Designee (DD) of Patient 2s Electronic Medical Record (EMR), DD stated she was not aware that Patient 2 was not seen since March 2024. DD stated there was nothing documented in Patient 2 s EMR stating she was not being seen. DD stated they will write a discharge order. 2.During a review of Patient 4s ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s ";Date Initial Nursing Assessment Initiated 3/1/2024" indicated ";Skin – wound on the head upon admission: cleanse with wound cleaner, apply, med honey, cover with island dressing." During a joint home visit on 5/1/2024 at 11;15 a.m. with LVN2 to Patient 4s home, LVN2 stated she changes Patient 4s top of head wound dressing twice a week by following what the admitting nurse told her to do. LVN2 stated she removes the old dressing, cleanse the wound with wound cleaner, apply ";the ointment" then redresses the wound. LVN2 stated she does not have measurements for Patient 4s head wound. CT1 stated a wound care nurse practitioner, CT1 unable to recall nurses name, comes every Monday to change Patient 4s head wound dressing. During a concurrent interview and record review on 5/2/2024 at 1:35 p.m. with the DD of Patient 4s EMR, DD stated, ";It has come to my attention that the wound company he is using now is not documenting or uploading their notes into our system." DD also stated that the HAs visiting nurse has not documented wound notes for Patient 4. DD stated patients documents need to be uploaded in their EMR system for all to see. DD stated that wound assessments are important to find out if the treatment being provided was effective. DD stated the communication and coordination is ";bad". DD called the Administrator (ADM) to request the wound care nurse information. DD stated the ADM told her that all contracts were seized by Entity 1 (EN1) in March 2024, and he did not have the wound care nurses contract or employee file. A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Plan of Care", dated April 2020, indicated, ";Policy...Bright and White Hospice will utilize a case management system to guide an interdisciplinary group to provide comprehensive, coordinated health care to patients and families/caregivers serviced by the hospice. It will be the responsibility of the Clinical Supervisor to assign a Case Manager who is a registered nurse. The Case Manager will be responsible for coordination of services with the interdisciplinary group from referral to discharge.

Based on interview and record review the Hospice Agency (HA) failed to ensure the Condition of Participation for License Professional Services was met as evidence by: --- 1. The HA failed to provide evidence their licensed providers were authorized and qualified to provide hospice services to seven of fourteen sample patients (Patient 1, Patient 2, Patient 4, Patient 9, Patient 10, Patient 11, and Patient 12). (Refer to L584). 2. The HA failed to ensure their Medical Social Worker, Physicians, and Spiritual Counselor participated in the planning of patients hospice care by not attending IDT meetings and not contributing to the development of their individualized plan of care for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 4, Patient 9, Patient 10, Patient 11, and Patient 12) plan of care (POC- an individualized care planned). (Refer to L585). 3. The HA failed to provide evidence their licensed professionals were involved and participated in the HAs quality assessment and performance improvement program (QAPI) for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). (Refer to L586). The cumulative effect of these systemic practices resulted in the HA not ensuring their license personnel were providing 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 (HA) failed to provide evidence their licensed providers were authorized and qualified to provide hospice services to seven of fourteen sample patients (Patient 1, Patient 2, Patient 4, Patient 9, Patient 10, Patient 11, and Patient 12). This failure had the potential to result in patient being taken care of unqualified and unauthorized staff. --- During an interview on 4/29/2024 at 11:15 a.m. with the Administrator (ADM), the ADM stated Entity 1 (EN1) seized all the HAs documents including employee files. ADM stated new employee files were in a van. During an interview on 5/2/2024 at 11:35 a.m. with ADM, ADM stated he did not have any employee records because EN1 took them all in March 2024. ADM stated there was no way to verify staffs qualifications. During an interview on 5/2/2024 at 12:05 p.m. with ADM, ADM stated he had no employee files. During an interview on 5/2/2024, at 5:41 p.m., a call was made to Medical Social Worker 1 (MSW 1) to the phone number provided. Representative 1 (Rep 1) answered the call and stated the phone number belonged to a social services company. Rep 1 stated MSW 1 was a social worker assistant, and he was being supervised by another social worker. A message was left for MSW 1 to return the call to the surveyor team. During a concurrent observation and interview on 5/4/2024, at 12:40 p.m., the Director of Nurses designee (DD) called MSW 1. DD stated MSW 1 was not answering the call. During a concurrent interview and record review on 5/4/2024 at 2 p.m. with the ADM of employee files, ADM provided DDs employee file. ADM did not provide other employee files. On 5/4/2024, at 5:47 p.m. a call was made to Medical Social Worker 2 (MSW 2) phone number as listed. Rep 1 answered the call. Message left to have MSW 2 return the call to the surveyor team. 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). A record review of Patient 1s document titled, ";Initial Orders and Plan of Care", dated 1/5/2024, did not indicate a plan of care was formulated. There was no indication of the skilled nursing services (SN) and medical social worker (MSW) frequency being provided. During an interview on 4/30/2024, at 1:09 p.m., DD stated the IDG group documented the meeting in the electronic medical record (EMR) right away. Each discipline had their own computer access, and each discipline entered their own note in the EMR. DD stated the IDG group, included the registered nurse (RN) and medical social worker (MSW) who met every two weeks. A record review of Patient 1s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/5/2024, did not have any entries/narratives documented for the SN and MSW. Further review of the record indicated names of the SN, MSW 1, and MSW 2. However, there was no signatures in the document. A record review of Patient 1s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/19/2024, did not have any entries/narratives documented for the SN and MSW. Further review of the record indicated names of the SN, MSW 1, and MSW 2. However, there was no signatures in the document. 2. A review of Patient 2s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 2s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 1/5/2024, indicated the form also indicated it was not singed by SN and MSW services. During a review of Patient 2s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated ";SW Report" was left blank. The form also indicated it was not singed by SN and MSW staff. During a review of Patient 2s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated ";SW Report" was left blank. The form also indicated it was not singed by SN and MSW staff. During a review of Patient 2s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated ";SW Report" was left blank. The form also indicated it was not singed by SN and MSW staff. 3. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated the form was not singed by SN and MSW staff. During a review of Patient 4s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated it was not singed by SN and MSW staff. During a review of Patient 4s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated ";SW Report" section was left blank. The form also indicated it was not singed by SN and MSW staff. 4. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an interview and record review on 4/30/2024, at 10:45 a.m., Patient 9s second caregiver (CG 2) stated she wrote all the visits Patient 9 has received in a notebook. The notebook indicated Patient 9 received visits from the HA on 3/27/2024, 4/10/2024, 4/13/2024, and 4/30/2024. CG 2 stated she did not remember a social worker coming to the home or talking on the phone with them. A record review of Patient 9s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/5/2024. The record indicated, ";SW Report IDT 4/5/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family." A record review of Patient 9s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/19/2024, indicated, ";SW Report IDT 4/19/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family. Further review of the record indicated names of the SN, MSW 1, and MSW 3. However, there were no signatures on the document. 5. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A record review of Patient 10s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 1/2/2024, indicated, ";SW Report IDT 1/2/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family." A record review of Patient 10s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", for dates: 1/26/2024, indicated patient declined MSW services. Further review of the record did not indicate the name and signature of the SN and MSW staff. 2/9/2024, indicated patient declined MSW services. Further review of the record did not indicate the name and signature of the SN and MSW staff. 2/23/2024, indicated patient declined MSW. Further review of the record did not indicate the name and signature of the SN and MSW staff. 3/8/2024, indicated patient declined MSW. Further review of the record did not indicate the name and signature of the SN and MSW staff. 3/22/2024, indicated patient declined MSW. Further review of the record did not indicate the name and signature of the SN and MSW staff. 6. A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 11s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated it was not singed by SN and MSW staff. During a review of Patient 11s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated it was not singed by SN and MSW staff. During a review of Patient 11s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated it was not singed by SN and MSW staff. During a review of Patient 11s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/19/2024, indicated was not singed by SN and MSW staff. 7. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease). A record review of Patient 12s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", for dates: 1/12/2024, indicated patient declined MSW services. Further review of the record did not indicate the name and signature of the SN and MSW staff. 1/26/2024, indicated patient declined MSW services. Further review of the record did not indicate the name and signature of the SN and MSW staff. 2/9/2024, indicated patient declined MSW services. Further review of the record did not indicate the name and signature of the SN and MSW staff. 2/23/2024, indicated patient declined MSW. Further review of the record did not indicate the name and signature of the SN and MSW staff. 3/22/2024, indicated patient declined MSW. Further review of the record did not indicate the name and signature of the SN and MSW staff. A review of the HAs undated document titled, ";Organizational Chart", indicated the name of MSW 1 and indicated, ";Medical Social Worker". A review of the HAs document titled, ";Disciplines List", indicated MSW 1 lived in Hemet, California (a city in Riverside county). The document also indicated MSW 2 lived in San Jacinto, California (a city in Riverside county). A review of the HAs policy and procedure titled, ";Scope of Services", dated April 2020, indicated, ";Policy: Bright and White Hospice provides hospice services that are intended to meet the physical, psychosocial, practical, and spiritual needs of patients and families/caregivers...core hospice services provided by nurses, social workers...are available 24 hours a day, seven (7) days a week."

Based on interview and record review the Hospice Agency (HA) failed to ensure their Medical Social Worker (MSW), Physicians, and Spiritual Counselor (SC) participated in the planning of patients hospice care by not attending IDT meetings and not contributing to the development of their individualized plan of care for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 4, Patient 9, Patient 10, Patient 11, and Patient 12) plan of care (POC- an individualized care planned). This failure resulted in patients not being properly evaluated which resulted in not being provided individualized focused care. --- 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During an interview on 4/30/2024, at 1:09 p.m., DD stated the IDG group documented the meeting in the electronic medical record (EMR) right away. Each discipline had their own computer access, and each discipline entered their own note in the EMR. DD stated the IDG group, composed of the RN, MSW, Chaplain, and doctor, met every two weeks. A record review of Patient 1s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/5/2024, did not have any entries/narratives documented for the doctor, RN, MSW, and chaplain report. Further review of the record indicated names of the RN, doctor, Medical Social Worker 1 (MSW 1), Medical Social Worker 2 (MSW 2) and Chaplain. However, there was no signatures in the document. A record review of Patient 1s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/19/2024, did not have any entries/narratives documented for the doctor, RN, MSW, and chaplain report. Further review of the record indicated names of the RN, doctor, MSW 1, MSW 2, and Chaplain. However, there was no signatures in the document. 2. During a review of Patient 2s medical record form titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 2s medical record form titled ";Date Initial Nursing Assessment Initiated 1/5/2024" indicated ";Need for comprehensive assessment – social work; spiritual care; dietician; physician; occupational therapist." The form also indicated ";Summary/Plan/Support Diagnosis: ... IDT notified of admission...". During a review of Patient 2s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 1/5/2024, indicated ";Physician Report" section was left blank. Lastly, the form also indicated it was not singed by any HA staff. During a review of Patient 2s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated ";Physician Report, Spiritual Care Report and SW Report" were left blank. The form also indicated it was not singed by any HA staff. During a review of Patient 2s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated ";Physician Report, Spiritual Care Report and SW Report" were left blank. The form also indicated it was not singed by any HA staff. During a review of Patient 2s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated ";Physician Report, Spiritual Care Report and SW Report" were left blank. The form also indicated it was not singed by any HA staff. During a concurrent interview and record review on 5/2/2024 at 2:14 p.m. with the Director of Nurses Designee (DD) of Patient 2s Electronic Medical Record (EMR), DD stated Patient 2s EMR did not contain MSW or SC documentation. 3. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form titled ";Date Initial Nursing Assessment Initiated 3/1/2024" indicated ";Need for comprehensive assessment – spiritual care; bereavement." The form also indicated it was not signed by HA staff. During a review of Patient 4s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated ";Physician Report" section was left blank. The form also indicated it was not singed by any HA staff. During a review of Patient 4s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated ";Physician Report" section was left blank. The form also indicated it was not singed by any HA staff. During a review of Patient 4s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated ";Spiritual Care Report, SW Report and Physician Report" sections were left blank. The form also indicated it was not singed by any HA staff. During a concurrent interview and record review on 5/2/2024 at 2:14 p.m. with DD of Patient 4s EMR, DD stated Patient 4s EMR did not contain MSW or SC documentation. 4. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an interview at the home visit on 4/30/2024, at 10:10 a.m., RN 1 stated the goal of the visit was to assess for pain. During the visit, RN did not assess Patient 9s blood sugar levels and did not assess Patient 9 for symptoms of high (hyperglycemia) or low (hypoglycemia) blood sugar. During a concurrent observation and interview during the home visit on 4/30/2024, at 10:21 a.m., RN 1 assessed Patient 9s upper chest. RN 1 stated there was a dry, white dressing on the upper right chest wall, with two ports coming out of the dressing. Patient 9s caregiver (CG 1) stated it was her access port for her dialysis (a clinical purification of blood, as a substitute for the normal function of the kidneys) treatment every Monday and Friday. During an interview at the home visit on 4/30/2024, at 10:40 a.m., CG 1 stated Patient 9s medication ";Januvia" was for her diabetes. During an interview on 5/2/2024, at 11:04 a.m., Medical Director 1 (MD 1) stated he was aware Patient 9 had diabetes. MD 1 stated he was expecting for the nursing staff to assess Patient 9s diabetes to make sure she was not getting hyperglycemic or hypoglycemic. MD 1 stated the nursing staff should report to him if there is anything unusual such as having hyper/hypo glycemia. MD 1 stated patients with diabetes should be monitored at least once a week. A record review of Patient 9s document titled, ";Initial Orders and Plan of Care", dated 3/27/2024, did not indicate a plan of care was formulated. A record review of Patient 9s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/5/2024. The record indicated, Spiritual Care Report: ";IDT 4/5/2024, Chaplain visits-Initial assessment within 5 days to provide support to patient and family. SW Report IDT 4/5/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family. A record review of Patient 9s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/19/2024, indicated, ";IDT 4/19/2024, Chaplain visits-Initial assessment within 5 days to provide support to patient and family. SW Report IDT 4/19/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family. The record did not indicate the IDG team addressed Patient 9s diabetes, dialysis, and dialysis port status. Further review of the record indicated names of the IDG members. However, there were no signatures. 5. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A record review of Patient 10s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 1/2/2024, indicated, ";Spiritual Care Report: IDT 1/2/2024, Chaplain visits-Initial assessment within 5 days to provide support to patient and family. SW Report IDT 1/2/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family." A record review of Patient 10s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", for dates: 1/26/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 2/9/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 2/23/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 3/8/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 3/22/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 6. A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 11s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated ";Physician Report" section was left blank. The form also indicated it was not singed by any HA staff. During a review of Patient 11s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated ";Physician Report" section was left blank. The form also indicated it was not singed by any HA staff. During a review of Patient 11s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated ";Physician Report" section was left blank. The form also indicated it was not singed by any HA staff. During a review of Patient 11s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/19/2024, indicated ";Physician Report" section was left blank. The form also indicated it was not singed by any HA staff. During a concurrent interview and record review on 5/2/2024 at 2:14 p.m. with DD of Patient 11s EMR, DD stated Patient 11s EMR did not contain MSW or SC documentation. 7. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease). A record review of Patient 12s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", for dates: 1/12/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 1/26/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 2/9/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 2/23/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. 3/22/2024, indicated patient declined MSW and Chaplain services. Further review of the record did not indicate the name and signature of the RN, MSW, and Chaplain. The doctors name was indicated, but there was no signature. During an interview on 4/30/2024 at 12:55 p.m. with the DD, DD stated the IDT meetings are conducted during admission and no later than the following day and then every two weeks. DD stated the Registered Nurse (RN), office staff, MSW, SC, and the doctor are called after the initial nursing assessment to verify patients medications, ancillaries, and DME (durable medical equipment: bed, oxygen, diapers, etc.). DD stated all disciplines have access with their personal log in information for the HAs EMR system where they need to document their concerns and sign. During an interview on 4/30/2024 at 2:40 p.m. with the Director of Nurses Designee (DD), DD stated that if there was no documentation in patients EMR from the MSW or SC, it was because either the patient and/or family/caregiver refused their services. DD stated the MSW and SC would need to document the refusal in IDT meetings. DD stated that when a patient declines MSW and/or SC services, both disciplines will attempt monthly visits. A review of the HAs policy and procedure titled, ";Comprehensive Assessment", dated April 2020, indicated, ";Procedure...5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum every 15 days."

Based on interview and record review the Hospice Agency (HA) failed to provide evidence their licensed professional staff were involved and participated in the HAs quality assessment and performance improvement program (QAPI – a data driven and proactive approach to quality improvement) for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This failure had the potential to result in the HA being unaware if their quality standards of care are being met. --- During an interview on 5/4/2024 at 12:47 p.m. with the Director of Nurses Designee (DD), DD stated the HA did not have a QAPI program for 2023 or 2024. DD stated QAPI program was needed to provide patients with quality care. During an interview on 5/4/2024 at 12:50 p.m. with License Vocational Nurse 1 (LVN1), LVN1 stated it was important to have a QAPI program to keep track and be aware if patients quality of care and goals are being met. 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During a concurrent interview and record review on 5/2/2024, at 1:30 p.m., the Director of Patient Care Services designee (DD) reviewed Patient 1s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/5/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. During an interview on 5/2/2024, at 11:14 a.m., DD stated the comprehensive assessment was a system assessment that is used to formulate the plan of care for the patient. A record review of Patient 1s document titled, ";Initial Orders and Plan of Care", dated 1/5/2024, did not indicate a plan of care was formulated. 2. A review of Patient 2s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 2s home, Patient 2 was not at home. LVN2 stated she has not seen Patient 2 since March. LVN2 stated Patient 2s Caretaker 1 (CT1) informed her that Patient 2 had left the home on 4/16/2024. LVN2 stated she did not document anything regarding Patient 2s status in the HAs EMR system. LVN2 stated she did not know if the physician was aware of Patient 2s status. LVN2 stated Patient 2 did not have a plan of care and that she checked Patient 2s vital signs and environment. During a review of Patient 2s EMR, the EMR indicated there was one documented plan of care for Patient 2 dated 1/5/2024. Patient 2s EMR form titled ";IDT plan of care and review of comprehensive assessment" dated 1/5/2024, 3/8/2024, 3/22/2024, and 4/5/2024, indicated the following sections were left blank ";Hospice Physician; Co-morbid Diagnosis; Physician Report; Spiritual Care Report; SW Report; Volunteer Report; and Eligibility Assessment – Current Numbers." All forms did not indicate any HAs staff signatures. During a concurrent interview and record review on 5/2/2024 at 11:10 a.m. with Medical Director 1 (MD1) of Patient 2s clinical notes, MD1 stated he did not have any notes for Patient 2. MD1 stated he did not know anything about Patient 2. During a concurrent interview and record review on 5/3/2024 at 11:14 a.m. with Medical Director 2 (MD2) of Patient 2s clinical notes, MD2 stated he did not have any recollection of seeing Patient 2 or writing her notes. 3. A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). During a record review on 4/29/2024, at 1:20 p.m., Patient 3s record did not have a comprehensive assessment by the nurse. During a concurrent interview and record review on 5/2/2024, at 1:34 p.m., the DD reviewed Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/12/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. During an interview on 4/30/2024, at 1:19 p.m., the DD stated the registered nurse who saw the patient was supposed to initiate the POC. The POC needed to include goals, interventions, and frequency of visits. The POC was used to follow the care of the patient. A record review of Patient 3s document titled, ";Initial Orders and Plan of Care", dated 4/25/2024, did not indicate a plan of care was formulated. 4. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form untitled, indicated ";Initial Nursing Assessment Initiated 3/1/2024"; Certification period from 3/1/2024 to 5/29/2024. The following sections were left blank: POLST signed; Advance Directive; Allergies; and Co-morbidities Surgery dates. During a review on 4/29/2024 at 1:23 p.m. of Patient 4s Electronic Medical Record (EMR) medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated the form was left blank. The form also indicted the signature sections for Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) were left blank. During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 4s home, LVN2 stated she visits Patient 4 twice a week for wound dressing change. LVN2 stated she did not have Patient 4s individualized plan of care. LVN2 stated she provided Patient 4s care by following the admitting nurse verbal instructions. LVN2 stated her visits include changing Patient 4s head wound dressing, checking his vital signs, and checking the facility for safety. Patient 4 stated he had cholesterol, diabetes, and a wound on top of his head. LVN2 stated she was not aware Patient 4 had diabetes mellitus. During an interview on 5/1/2024 at 11:15 a.m. with Patient 4s Caretaker 1 (CT1), CT1 stated a Nurse Practitioner sees Patient 4 on Mondays. CT1 stated he has told and ask the Nurse Practitioner about Patient 4s diabetes medication and monitoring machine. CT1 stated Nurse Practitioner has told him that he will inform a doctor, but the doctor has not seen Patient 4. During a concurrent interview and record review on 5/2/2024 at 11:13 a.m. with Medical Director 1 (MD1) of Patient 4s clinical notes, MD1 stated he did not dictate any notes for Patient 4. During a concurrent interview and record review on 5/2/2024 at 1:35 p.m. with DD of Patient 4s EMR, DD stated Patient 4 did not have a plan of care. DD stated Patient 4 needed to have a plan of care. 5. A review of Patient 8s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 8s medical record form untitled, indicated ";Initial Nursing Assessment Initiated 4/25/2024" form indicated it was not complete. During a concurrent interview and record review on 4/30/2024 at 3:15 p.m. with the DD of Patient 8s EMR, DD stated Patient 8s start of care date was 4/25/2024. DD stated she was unable to locate an initial nursing assessment for Patient 8 that was supposed to be completed by 4/25/2024. DD stated Patient 8 did not have a documented plan of care. During a concurrent interview and record review on 5/2/2024 at 10:48 a.m. with Medical Director 1 (MD1) of Patient 8s clinical notes, MD1 stated he did not have any notes for Patient 8. During a concurrent interview and record review on 5/3/2024 at 11:23 a.m. with Medical Director 2 (MD2) of Patient 8s clinical notes, MD2 stated he did not have any records for Patient 8. MD2 stated he did not see Patient 8. 6. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an interview at the home visit on 4/20/2024, at 9:55 a.m. Registered Nurse 1 (RN 1) stated Patient 9 had heart failure, diabetes (elevated levels of sugar in the blood), and high blood pressure. RN 1 stated he did not have a POC for the visit. During a concurrent interview and record review on 4/20/2024, at 9:59 a.m., RN 1 reviewed the surveyors Patient 9s record titled, ";Initial Orders and Plan of Care", for certification period 3/27/2024 to 6/24/2024. RN 1 stated the record did not have any interventions and goals written on it. A record review of Patient 9s document titled, ";Initial Orders and Plan of Care", dated 3/27/2024, did not indicate a plan of care was formulated. 7. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A review of Patient 10s document titled, ";Initial Orders and Plan of Care", dated 1/2/2024, did not indicate a plan of care was formulated. 8. A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). A review of Patient 11s document titled, ";Initial Orders and Plan of Care", dated 2/27/2024, did not indicate a plan of care was formulated. 9. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). A review of Patient 12s document titled, ";Initial Orders and Plan of Care", dated 1/9/2024, did not indicate a plan of care was formulated. During an interview on 4/30/2024 at 12:55 p.m. with the DD, DD stated the Registered Nurse who initially assesses the patient initiates their plan of care. DD stated patients plan of care are based on their needed interventions to meet their goals. DD stated patients plan of care indicate their medications, disciplines with their frequencies, and their needed interventions. During an interview on 5/2/2024 at 10:48 a.m. with MD1, MD1 stated anyone who sees patients that do not have a plan of care will not know what is going on with the patient. MD1 stated that the whole purpose of the medical team was to be able to follow what is occurring with the patient. A record review of the HAs policy and procedure titled, ";Hospice Nursing Care", dated April 2020, indicated, ";Procedure...3.The hospice nurse will...Q. Participate in quality assessment performance improvement teams and activities." A review of the HAs policy and procedure titled, ";Scope of Services", dated April 2020, indicated, ";Policy: Bright and White Hospice provides hospice services that are intended to meet the physical, psychosocial, practical, and spiritual needs of patients and families/caregivers...core hospice services provided by nurses, social workers, physicians, and bereavement counselors...are available 24 hours a day, seven (7) days a week...3. An interdisciplinary group of professionals and volunteers will develop with each patient and family/caregiver a plan of care, which include, as appropriate, the following services: A. Physician. B. Registered Nurse. C. Medical Social Worker...E. Spiritual Support...".

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for Core Services (physician services, nursing services, medical social services, and counseling services [bereavement, dietary, and spiritual]) was met as evidenced by: --- 1. The HA failed to ensure eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) had their terminal illness (illness with a prognosis of having six months of life or less to live) managed and overseen by a physician. (Refer to L590). 2. The HA failed to ensure a Registered Nurse supervised services provided by Certified Home Health Aide 1 (CHHA1) and Licensed Vocational Nurse 2 (LVN2) for one of fourteen sampled patients (Patient 4). (Refer to L 591). The cumulative effect of these systemic practices resulted in the HA not providing the core services/care as required and had the potential for the patients not to receive healthcare services that could affect their quality of life.

Based on interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) had their terminal illness managed and overseen by a physician. This failure resulted in patients receiving hospice services without being certified for hospice care and without a physician oversight which had the potential to cause harm and distress to the patients by not having their needs met. --- Findings: During a review of Patient 1s Patient Face Sheet (admission record), the Patient Face Sheet indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During a review of Patient 1s Certification of Terminal Illness, for certification period 1/5/2024-4/3/2024, indicated a narrative was written and the hospice doctors name was Medical Doctor 2 (MD 2). During a review of Patient 1s Certification of Terminal Illness, for certification period 4/4/2024 -7/2/2024, indicated a narrative was written and the hospice doctors name was MD 2. The section titled, ";Hospice Physician Signature," and ";Date," were blank. During an interview on 5/3/2024, at 11:25 a.m., with MD 2, MD2 stated, he did not see and did not examine Patient 1. During a review of Patient 2s Patient Face Sheet, the Patient Face Sheet indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). The Patient Face Sheet indicated MD2 was her attending physician. During a review of Patient 2s Certification of Terminal Illness (CTI) form, dated 1/5/2024 to 3/4/2024, the Certification of Terminal Illness form indicated MD3 was listed as her hospice physician and MD2 was listed as her attending physician. The Certification of Terminal Illness form indicated it was not signed by MD2 or MD3. During a review of Patient 2s Certification of Terminal Illness (CTI) form dated 3/5/2024 to 5/3/2024, the Certification of Terminal Illness form indicated MD2 was listed as Patient 2s hospice physician and the form was not signed by MD2. During a review of Patient 2s Initial Orders and Plan of Care form, dated 1/5/2024, the Initial Orders and Plan of Care form indicated MD3 was listed as the ";Hospice Physician," and MD2 as the ";Attending Physician." The Initial Orders and Plan of Care form indicated it was not signed by MD3 or MD2. During a concurrent interview and record review, on 4/30/2024, at 3:37 p.m., with the Director of Nurses Designee (DD), Patient 2s Electronic Medical Record (EMR) was reviewed. The DD stated both of Patient 2s CTIs were not signed. DD stated the agency did not have CTI forms for Patient 2 and the agency did not upload into Patient 2s EMR. During a telephone interview on 5/2/2024, at 11:10 a.m., with Medical Doctor 1 (MD1), MD1 stated he attempted to see Patient 2 on 3/9/2024, but Patient 2 was not home. MD1 stated he did not recall certifying Patient 2 for hospice services. MD1 stated, ";I dont know anything about her." During a telephone interview on 5/3/2024 at 11:14 a.m. with MD2, MD2 stated he did not have any recollection of seeing Patient 2. MD2 stated he did not have written notes for Patient 2. During a review of Patient 3s Patient Face Sheet, the Patient Face Sheet indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). During a record review of Patient 3s Certification of Terminal Illness, for certification period 4/25/2024-6/23/2024, the Certification of Terminal Illness indicated a narrative was written and the hospice doctors name was MD 2. The record was not signed. During an interview on 5/3/2024, at 11:26 a.m., with MD 2, MD2 stated he had not seen and examined Patient 3. During a review of Patient 4s Patient Face Sheet, the Patient Face Sheet indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). The Patient Face Sheet indicated MD2 was Patient 4s attending physician. During a review of Patient 4s Certification of Terminal Illness dated 3/1/2024 to 5/29/2024, the Certification of Terminal Illness indicated MD1 was listed as his hospice and attending physician and was not signed by MD1. During a review of Patient 4s Physician Order Details, dated 3/1/2024, the Physician Order Details indicated MD3 was listed under ";Physician." The Physician Order Details indicated it was not signed by MD3. During an interview on 5/1/2024, at 11:15 a.m., with Patient 4s Caretaker 1 (CT1), CT1 stated Patient 4 had diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels) and needed medication for his condition. CT1 stated he requested a doctors home visit a month ago (April 2024) to the wound nurse who saw Patient 4 on Mondays. During a telephone interview on 5/2/2024, at 11:13 a.m. with MD1, MD1 stated he did not dictate notes for Patient 4. MD1 stated he did not recall writing a CTI for Patient 4. During a telephone interview on 5/3/2024, at 11:18 a.m., with MD2, MD2 stated he did not have any notes for Patient 4. MD2 stated he had not seen Patient 4. During a review of Patient 5s Date Initial Nursing Assessment dated 1/7/2024, the Date Initial Nursing Assessment indicated Patient 5 had a hospice diagnosis of end stage heart failure (heart unable to pump adequately, shortness of breath, fatigue, and irregular heartbeat even while at rest). During a review of Patient 5s Certification of Terminal Illness, dated 1/7/2024 to 3/6/2024, the Certification of Terminal Illness, indicated MD3 was listed as her hospice physician. The Certification of Terminal Illness form indicated MD2 was listed as her attending physician and was not signed by MD2 or MD3. During a review of Patient 5s Certification of Terminal Illness dated 3/3/2024, the Certification of Terminal Illness indicated MD1 was listed as his hospice physician and the Certification of Terminal Illness was not signed by MD1. During a review on 4/30/2024, at 3:06 p.m., of Patient 5s EMR form titled ";End of Care Summary," dated 3/28/2024, indicated MD2 was listed under ";Physician." The End of Care Summary form indicated it was left blank and it was not signed by MD2. During a telephone interview on 5/2/2024, at 11:18 a.m., with MD1, MD1 stated he saw Patient 5 on 3/24/2024 and certified him for hospice care. MD1 stated he did not discharge Patient 5 and as far as he knew Patient 5 was receiving hospice care. During a telephone interview on 5/3/2024, at 11:20 a.m., with MD2, MD2 stated he did not have notes regarding Patient 5. During a review of Patient 7s Date Initial Nursing Assessment, dated 1/9/2024, the Date Initial Nursing Assessment indicated Patient 7 had a hospice diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 7s Certification of Terminal Illness, dated 1/9/2024 to 3/8/2024, indicated MD3 was listed as his hospice physician and was not signed by MD3. During a review of Patient 7s Certification of Terminal Illness dated 3/6/2024, the Certification of Terminal Illness indicated there was no listed physicians name. During a review of Patient 7s Initial Orders and Plan of Care, dated 1/9/2024, the Initial Orders and Plan of Care indicated MD3 was listed as the ";Hospice Physician." The Initial Orders and Plan of Care form indicated it was not signed by MD3. During a review of Patient 7s End of Care Summary, dated 4/1/2024, the End of Care Summary did not indicate Patient 7s reason for discharge. The End of Care Summary indicated MD2 was listed under ";Physician," and was not signed by MD2. During a telephone interview on 5/2/2024, at 11:22 a.m., with MD1, MD1 stated he did not treat Patient 7. During a review of Patient 8s Patient Face Sheet, the Patient Face Sheet indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). The Patient Face Sheet indicated MD1 was listed as the ";Attending Physician," and MD2 was listed as the ";Hospice Physician." During a review of Patient 8s Certification of Terminal Illness, dated 4/25/2024 to 6/23/2024, the Certification of Terminal Illness indicated MD1 was listed as her hospice and attending physician and was not signed by MD1. During a review of Patient 8s Physician Order Details, dated 4/24/2024, indicated ";Refer to hospice care for evaluation and admission." The Physician Order Details indicated MD1 was listed as the ";Physician". During a concurrent interview and record review on 4/30/2024 at 3:48 p.m. with the DD of Patient 8s EMR, DD stated Patient 8s CTI is not signed by a physician. During a telephone interview on 5/2/2024, at 11:15 a.m., with MD1, MD1 stated he did not have any records for Patient 8. MD1 stated he did not treat Patient 8. During a telephone interview on 5/3/2024, at 11:23 a.m., with MD2, MD2 stated he did not have records for Patient 8. MD2 stated he did not see Patient 8. During a review of Patient 9s Patient Face Sheet, the Patient Face Sheet indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During a review of Patient 9s Certification of Terminal Illness, for certification period 3/27/2024 to 6/24/2024, the Certification of Terminal Illness indicated, ";I have reviewed and agree with the Plan of care that includes Initial Orders and Plan of Care, Medication Profile and Plan of Care Problems (identified in assessments) and admission to hospice." The Certification of Terminal Illness indicated MD 2s name and was not sign. During an interview on 5/3/2024, at 11:27 a.m., with MD 2, MD 2 stated he had not seen and examined Patient 9. During a review of Patient 10s Patient Face Sheet, the Patient Face Sheet indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During a review of Patient 10s Certification of Terminal Illness, for certification period 1/2/2024- 3/31/2024, the Certification of Terminal Illness indicated a narrative was written and the hospice doctors name was MD 3. The record was not signed. During a review of Patient 10s Certification of Terminal Illness, for certification period 4/1/2024 -6/29/2024, the Certification of Terminal Illness indicated a narrative was written and the hospice doctors name was MD 2. The Certification of Terminal Illness indicated the section titled, ";Hospice Physician Signature," and ";Date," were blank. During a review of Patient 11s Patient Face Sheet, indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). The Patient Face Sheet indicated MD2 was listed as the hospice and attending physician. During a review of Patient 11s Certification of Terminal Illness dated 2/27/2024 to 4/26/2024, the Certification of Terminal Illness indicated MD1 was listed as her hospice and attending physician. The Certification of Terminal Illness form indicated it was not signed by MD1. During a review of Patient 11s Certification of Terminal Illness, dated 4/27/2024, indicated MD1 was listed as her hospice physician. The Certification of Terminal Illness indicated it was not signed by MD1. During a review of Patient 11s Initial Orders and Plan of Care, dated 2/27/2024, the Initial Orders and Plan of Care indicated MD2 was listed as the hospice and attending physician. The form also indicated it was not signed by MD2. During a review of Patient 11s Physician Order Details, dated 4/18/2024, indicated ";Recertify patient... under routine care for the 6th benefit period starting 4/27/2024 to 6/25/2024...". The Physician Order Details form indicated MD1 was listed as the ";Physician," and was not signed by MD1. During a concurrent interview and record review on 4/30/2024, at 3:53 p.m. with the DD of Patient 11s EMR, DD stated Patient 11s CTI was not signed. During a telephone interview on 5/2/2024, at 11:16 a.m., with MD1, MD1 stated he did not certify Patient 11 for hospice services. MD1 stated Patient 11 did not meet hospice criteria. During a telephone interview on 5/3/2024, at 11:23 a.m., with MD2, MD2 stated he did not treat Patient 11. During a review of Patient 12s Patient Face Sheet, the Patient Face Sheet indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). During a review of Patient 12s Certification of Terminal Illness, for certification period 1/9/2024-4/7/2024, the Certification of Terminal Illness indicated a narrative was written and the hospice doctors name was MD 3. The Certification of Terminal Illness was not signed. During a review of Patient 12s Certification of Terminal Illness, for certification period 4/8/2024 -7/6/2024, the Certification of Terminal Illness indicated a narrative was written and the hospice doctors name was MD 1. The Certification of Terminal Illness indicated the section titled, ";Hospice Physician Signature" and ";Date" were blank. During a review of HAs form titled ";Organizational Chart," undated, the Organizational Chart indicated MD1 and MD2 were listed as their ";Medical Director." During an interview on 4/29/2024, at 9:43 a.m., with the Administrator (ADM), an entrance conference was conducted with the ADM. During the entrance conference the ADM stated MD1 was the HAs Medical Director and MD2 was another physician employed. During an interview on 4/30/2024, at 12:55 p.m., with Director of Nurses Designee (DD), DD stated the physicians completed the patients Certification of Terminal Illness (CTI) in the HAs EMR initially and at every recertification. DD stated CTIs were important to be able to follow physician orders because the HA was under their supervision. During a concurrent interview and record review on 4/30/2024, at 3:30 p.m., with the DD of the HAs EMR, DD stated if the CTI form did not indicate ";E-signed" it meant it was not signed. DD stated the arrow next to the physicians name was used to upload documents. During a telephone interview on 5/2/2024, at 10:48 a.m., with MD1, MD1 stated he started working as the medical director for the HA in February 2024. MD1 stated he has not logged into the HAs EMR system. MD1 stated he dictated his notes on a WORD document (an electronic document, owned by Microsoft-a software company) then sends them via email to the HA. MD1 stated he would see and certified patients for hospice care but he had not signed any patients CTI. During a telephone interview on 5/3/2024, at 11:03 a.m., with MD2, MD2 stated he wrote patient notes in a notebook and then email a photograph of his notes to the HA. MD2 stated after emailing a photograph of patients notes that would be the end of his process. MD2 stated he did not document any notes in the HAs EMR system. During a telephone interview on 5/4/2024, at 11:55 a.m., with MD3, MD3 stated he was the medical director for the HA up until January or February 2024. MD3 stated he did not treat or see HAs patients in March, April, or May of 2024. A review of the HAs policy and procedure titled, ";Scope of Services", dated April 2020, indicated, ";Policy: Bright and White Hospice provides hospice services that are intended to meet the physical, psychosocial, practical, and spiritual needs of patients and families/caregivers...core hospice services provided by...physicians...are available 24 hours a day, seven (7) days a week...3. An interdisciplinary group of professionals and volunteers will develop with each patient and family/caregiver a plan of care, which include, as appropriate, the following services: A. Physician."

Based on interview and record review the Hospice Agency (HA) failed to ensure a Registered Nurse supervised services provided by Certified Home Health Aide 1 (CHHA1) and Licensed Vocational Nurse 2 (LVN2) for one of fourteen sampled patients (Patient 4). This failure had the potential for Patient 4 to experience harm. --- Findings: During a review of Patient 4s Patient Face Sheet (admission record), indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s Physician Order Details, dated 3/1/2024, the Physician Order Details indicated ";SN (skilled nurse): 1 per week and 1-2 as needed visit/s...". The Physician Order Details indicated ";CHHA – service offered but declined." During an interview on 5/1/2024, at 11:15 a.m., with Patient 4s Caretaker 1 (CT1), CT1 stated Patient 4 received hospice CHHA services twice a week, on Tuesdays and Thursdays. During a concurrent interview and record review on 5/2/2024, at 11:50 a.m., with the Director of Nurses Designee (DD) of Patient 4s Electronic Medical Record (EMR), the DD stated Patient 4 did not have a documented CHHA care plan or CHHA visit notes since his start of care, 3/1/2024, in his EMR. The DD stated Patient 4 did not have a physician order for CHHA services, and that the HA received CHHA1s routing sheets that indicated the CHHA1 saw Patient 4 twice a week. The DD stated CHHA supervisory visits were important to know if the CHHA was following the patients planned care. DD stated CHHA1 did not have a plan of care for Patient 4. During a concurrent interview and record review on 5/2/2024, at 2:14 p.m., with the DD of Patient 4s EMR, the DD stated there were no Licensed Vocational Nurses (LVN) or CHHA supervisory visit notes. The DD stated LVN supervisory notes were supposed to be done monthly. The DD stated CHHA supervisory notes were supposed to be done every two weeks. The DD stated, ";LVN and CHHA supervisory visit to be aware if they are compliant with POC if they are treating the patient right including the treatment and intervention they are doing." A review of the HAs policy and procedure titled, ";Scope of Services", dated April 2020, indicated, ";Procedure...3. An interdisciplinary group of professionals and volunteers will develop with each patient and family/caregiver a plan of care, which will include as appropriate, the following services...H. Hospice aide...4. Routine home visits will be provided according to the plan of care including scope and frequency." A review of the HAs policy and procedure titled, ";Hospice Nursing Care", dated April 2020, indicated, ";Procedure...4. The hospice registered nurse will supervise...hospice aides..., per organizational policy."

Based on interview and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for organization and administration of services as follows: --- On 5/3/2024 at 10:29 a.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the facilitys Director of Nurses Designee (DD). 1. The hospice agency (HA) failed to ensure the governing body and administrator, assumed full responsibility for the day-to-day operation of the hospice services and provision of care for nine of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). The HA failed to ensure that the care, services, and continuous assessment of patient health status were provided to nine of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) assessed to receive hospice care. (Refer to L 651). The cumulative effect of these systemic practices resulted in Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12 did not have a continued assessment of the care being provided that could potentially not identify change in patients conditions and could potentially affect the patients care and services that could lead to hospitalization and death. The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with Federal regulations for organization and administration of services.

Based on interview, and record review, for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12), the Hospice Agency (HA) failed to: 1). Ensure the governing body and Administrator assumed full responsibility for the day-to-day operation and the provision of hospice care and services. 2). Ensure continuous, patients health assessment and ensuring quality patient care and services were provided to nine of fourteen sampled patients assessed to receive hospice care. The cumulative effect of these systemic practice resulted in Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12 did not have a continued assessment of the care being provided that had the potential that patients changes in conditions will not be identified. This failure could also affect the quality of patients care and services that could lead to complications, hospitalization and death. On 5/3/2024 at 10:29 a.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the facilitys Director of Nurses (DON) designee. --- During an interview on 4/29/2024, at 9:43 a.m., the Administrator (ADM) stated the Director of Nurse (DON) was on maternity leave and the Designee (DD) was visiting patients. The ADM stated he did not know who the Spiritual Counselor, Medical Social Worker, or Volunteer Coordinator were. The ADM stated he was not clinical, nursing, or medical personnel. During an interview on 4/30/2024, at 12:55 p.m., with the Director of Nurses Designee (DD), DD stated she was appointed to the position last week. The DD stated she had worked for the agency as a field staff visiting nurse and case management since 8/16/2023. During an interview on 5/2/2024, at 11:35 a.m., the ADM stated the DON was on maternity leave since before December 2023. The ADM stated the previous Director of Nursing Designee (PDD) left after having heart surgery. ADM was not sure about the dates and stated PDD left either last year at the end of the year, or on the first month of this year. The ADM stated he did not have employee records or any way of verifying the qualifications of all the staff working at the HA because all documents were taken by the Office of Inspector General in March 2024. The ADM stated he did not remember who was covering for the DON between January through last week after the DD began her employment. During an interview on 5/2/2024, at 1:55 p.m., the ADM stated Registered Nurse 2 (RN 2) was the Director of Nursing Designee prior to the DD. ADM provided RN2s contact information as requested. On 5/2/2024, at 5:11 p.m., a call was made to the DON. The DON did not answer the call. Message was left to return the call. During an interview on 5/2/2024, at 5:16 p.m., RN 2 stated she did not feel comfortable answering questions about the HA and stated she was never the DON or DON designee for the HA. On 5/4/2024, at 12:37 a.m., the DD called the DON. The DON did not answer the call. During an interview on 5/4/2023, at 2:34 p.m., the DD stated the previous Director of Nursing 2 (PDD2) was the Director of Nursing Designee from December 2023 until last week. On 5/4/2024, at 2:35 p.m., the DD called PDD 2. The PDD 2 did not answer the call. 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During a concurrent interview and record review on 5/2/2024, at 1:30 p.m., the Director of Nurses Designee (DD) reviewed Patient 1s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/5/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. During an interview on 5/2/2024, at 11:14 a.m., DD stated the comprehensive assessment was a system assessment that was used to formulate the plan of care for the patient. A record review of Patient 1s document titled, ";Initial Orders and Plan of Care", dated 1/5/2024, did not indicate a plan of care was formulated. 2. A review of Patient 2s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 2s EMR, the EMR indicated there was one documented plan of care for Patient 2 dated 1/5/2024. Patient 2s EMR form titled ";IDT plan of care and review of comprehensive assessment" dated 1/5/2024, 3/8/2024, 3/22/2024, and 4/5/2024, indicated the following sections were left blank ";Hospice Physician; Co-morbid Diagnosis; Physician Report; Spiritual Care Report; SW Report; Volunteer Report; and Eligibility Assessment – Current Numbers." All forms did not indicate any HAs staff signatures. During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 2s home, Patient 2 was not at home. LVN2 stated she has not seen Patient 2 since March. LVN2 stated Patient 2s Caretaker 1 (CT1) informed her that Patient 2 had left the home on 4/16/2024. LVN2 stated she did not document anything regarding Patient 2s status in the HAs EMR system. LVN2 stated she did not know if the physician was aware of Patient 2s status. LVN2 stated Patient 2 did not have a plan of care and that she checked Patient 2s vital signs and environment. During an interview on 5/2/2024 at 12:04 p.m. with DD, DD stated she found out Patient 2 had not been seen since March. DD stated there was nothing documented in Patient 2s EMR about the subject and would request a discharge date of yesterday. During a concurrent interview and record review on 5/2/2024 at 11:10 a.m. with Medical Director 1 (MD1) of Patient 2s clinical notes, MD1 stated he did not have any notes for Patient 2. MD1 stated he did not know anything about Patient 2. During a concurrent interview and record review on 5/3/2024 at 11:14 a.m. with Medical Director 2 (MD2) of Patient 2s clinical notes, MD2 stated he did not have any recollection of seeing Patient 2 or writing her notes. 3. A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). During a record review on 4/29/2024, at 1:20 p.m., Patient 3s record did not have a comprehensive assessment by the nurse. During a concurrent interview and record review on 5/2/2024, at 1:34 p.m., the DD reviewed Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/12/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. During an interview and record review on 5/4/2024, at 11:50 a.m., DD submitted Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 4/25/2024. DD stated she had given the surveyor the initial nursing assessment from another certification period. DD provided document titled, ";Document History", printed on 5/4/2024 and indicated the assessment record was created on 4/30/2024, day 2 of the survey. During an interview on 4/30/2024, at 1:19 p.m., the DD stated the registered nurse who saw the patient was supposed to initiate the POC. The POC needed to include goals, interventions, and frequency of visits. The POC was used to follow the care of the patient. A record review of Patient 3s document titled, ";Initial Orders and Plan of Care", dated 4/25/2024, did not indicate a plan of care was formulated. 4. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form untitled, indicated ";Initial Nursing Assessment Initiated 3/1/2024"; Certification period from 3/1/2024 to 5/29/2024. The following sections were left blank: POLST signed; Advance Directive; Allergies; and Co-morbidities Surgery dates. During a review on 4/29/2024 at 1:23 p.m. of Patient 4s Electronic Medical Record (EMR) medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated the form was left blank. The form also indicted the signature sections for Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) were left blank. During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 4s home, LVN2 stated she did not have Patient 4s individualized plan of care. LVN2 stated she provided Patient 4s care by following the admitting nurse verbal instructions. Patient 4 stated he had cholesterol, diabetes, and a wound on top of his head. LVN2 stated she was not aware Patient 4 had diabetes mellitus. During an interview on 5/1/2024 at 11:15 a.m. with Patient 4s Caretaker 1 (CT1), CT1 stated a Nurse Practitioner sees Patient 4 on Mondays. CT1 stated he has told and ask the Nurse Practitioner about Patient 4s diabetes medication and monitoring machine. CT1 stated Nurse Practitioner has told him that he will inform a doctor, but the doctor has not seen Patient 4. During a concurrent interview and record review on 5/2/2024 at 11:13 a.m. with Medical Director 1 (MD1) of Patient 4s clinical notes, MD1 stated he did not dictate any notes for Patient 4. During a concurrent interview and record review on 5/2/2024 at 1:35 p.m. with DD of Patient 4s EMR, DD stated Patient 4 did not have a plan of care. DD stated Patient 4 needed to have a plan of care. 5. A review of Patient 8s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 8s medical record form untitled, indicated ";Initial Nursing Assessment Initiated 4/25/2024" indicated it was not complete. The following areas were not assessed vital signs to include blood pressure, temperature, pulse, respiratory rate; current weight; functional limitation, activities permitted, mental status, memory recall, skin, musculoskeletal, sensory, cardiovascular, gastrointestinal, pain assessment, respiratory, endocrine, nutrition/hydration, genitourinary, reproductive, additional assessment, activity of daily living, psychosocial assessment, spiritual assessment, skilled care/Services provided, coordination of care, equipment/supplies, plan of care, eligibility assessment, teaching, need for comprehensive assessment, attending physician, and summary/plan/support diagnosis. During a concurrent interview and record review on 4/30/2024 at 3:15 p.m. with the DD of Patient 8s EMR, DD stated Patient 8s start of care date was 4/25/2024. DD stated she was unable to locate an initial nursing assessment for Patient 8 that was supposed to be completed by 4/25/2024. DD stated Patient 8 did not have a documented plan of care. During a review of Patient 8s medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 4/26/2024, indicated there were no signatures in sections Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) were left blank. The form also indicated Medical Doctor 1 (MD1) and MD2s names were printed in section ";Physician Name, Signature, Date". During a concurrent interview and record review on 5/2/2024 at 10:48 a.m. with Medical Director 1 (MD1) of Patient 8s clinical notes, MD1 stated he did not have any notes for Patient 8. During a concurrent interview and record review on 5/3/2024 at 11:23 a.m. with Medical Director 2 (MD2) of Patient 8s clinical notes, MD2 stated he did not have any records for Patient 8. MD2 stated he did not see Patient 8. 6. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an interview at the home visit on 4/20/2024, at 9:55 a.m. Registered Nurse 1 (RN 1) stated Patient 9 had heart failure, diabetes (elevated levels of sugar in the blood), and high blood pressure. RN 1 stated he did not have a POC for the visit. During a concurrent interview and record review on 4/20/2024, at 9:59 a.m., RN 1 reviewed the surveyors Patient 9s record titled, ";Initial Orders and Plan of Care", for certification period 3/27/2024 to 6/24/2024. RN 1 stated the record did not have any interventions and goals written on it. During an interview at the home visit on 4/20/2024, at 10:10 a.m., RN 1 stated the goal of the visit was to assess for pain. During the visit, RN did not assess Patient 9s blood sugar levels and did not assess Patient 9 for symptoms of high (hyperglycemia) or low (hypoglycemia) blood sugar. During an interview on 5/2/2024, at 11:04 a.m., Medical Director 1 (MD 1) stated he was aware Patient 9 had diabetes. MD 1 stated he was expecting for the nursing staff to assess Patient 9s diabetes to make sure she was not getting hyperglycemic or hypoglycemic. MD 1 stated the nursing staff should report to him if there is anything unusual such as having hyper/hypo glycemia. MD 1 stated patients with diabetes should be monitored at least once a week. MD 1 stated he was not aware Patient 9 did not have a POC. MD 1 stated the importance of having a POC was to follow standard regiment for each disease. Whoever is doing care, they can follow along and see what the progress is. MD 1 stated the risk of not having a POC is not knowing what is going on with the patient. That would be the whole purpose of the whole medical team, to know what is happening with the patient. During a concurrent interview and record review on 5/2/2024, at 11:14 a.m., DD reviewed Patient 9s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 3/27/2024. DD reviewed section ";Endocrine" and stated the record indicated ";WNL" (within normal limits). DD stated the record should have had a narrative about diabetes to include blood sugar levels. DD stated the assessment focused on the heart failure. DD stated diabetes did have an effect on heart failure and should have been assessed. DD stated the system assessment was important because that is what was used to formulate the plan of care for the patient. A record review of Patient 9s document titled, ";Initial Orders and Plan of Care", dated 3/27/2024, did not indicate a plan of care was formulated. 7. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A review of Patient 10s document titled, ";Initial Orders and Plan of Care", dated 1/2/2024, did not indicate a plan of care was formulated. 8. A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). A review of Patient 11s document titled, ";Initial Orders and Plan of Care", dated 2/27/2024, did not indicate a plan of care was formulated. During a concurrent interview and record review on 5/2/2024 at 11:16 a.m. with Medical Director 1 (MD1) of Patient 11s clinical notes, MD1 stated Patient 11 did not meet hospice criteria and did not admit her to hospice care. During a concurrent interview and record review on 5/3/2024 at 11:23 a.m. with Medical Director 2 (MD2) of Patient 11s clinical notes, MD2 stated he did not see Patient 11. 9. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). A review of Patient 12s document titled, ";Initial Orders and Plan of Care", dated 1/9/2024, did not indicate a plan of care was formulated. During an interview on 4/30/2024 at 12:55 p.m. with the Director of Nurses Designee (DD), DD stated the HA ";tries" to conduct the initial interdisciplinary team meetings during the admission process and no later than the following day. DD stated MSW and SC services are offered on admission and are send out despite the patient and/or family/care giver refusal. DD stated the HAs Registered Nurse, office staff, the assigned visiting nurse, Medical Social Worker, Spiritual Counselor, and physician are called to verify patients medications, ancillaries, and durable medical equipment (DME). DD stated all disciplines have individualized access to log into the HAs EMR system. DD stated all disciplines were to log into the HAs EMR system to document their concerns and sign in their attendance. A review of the HAs policy and procedure titled, ";Admission Criteria and Process", dated April 2020, indicated, ";Policy...Once a patient is admitted to service, the organization will be responsible for providing care and services within its financial and service capabilities, mission, and applicable law and regulations." A review of the HAs policy and procedure titled, ";Scope of Services", dated April 2020, indicated, ";Procedure...3. An interdisciplinary group of professionals and volunteers will develop with each patient and family/caregiver a plan of care...4. Routine home visits will be provided according to the plan of care including scope and frequency." A review of the HAs policy and procedure titled, ";Interdisciplinary Group Plan of Care", dated April 2020, indicated, ";Policy: The hospice interdisciplinary group will retain professional management responsibilities for the provision of services, including inpatient care, and will insure that services are furnished in a safe and effective manner...Procedure: 1. Each patient will be assigned a Case Manger by the Clinical Director/Director of Patient Care Services or Clinical Supervisor upon admission, based on patients needs and level of care required, geographic area, and qualifications of personnel needed." During a review of HAs form titled ";Job Title/Position: Executive Director/Administrator" dated 5/4/2024, indicated ";The Executive Director/Administrator is responsible for the overall direction of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements, and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy." ..

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Medical Director was met as evidenced by: --- 1. The HA failed to ensure there was a contract with their appointed Medical Director (MD1) for eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). (Refer to L666). 2. The HA failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial certifications for twelve of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) to support diagnosis of the patients' terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The agency failed to ensure there was a physicians signature and documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice care and services. (Refer to L667). 3. The HA failed to ensure 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 six of fourteen sampled patients (Patient 1, Patient 2, Patient 7, Patient 10, Patient 11, and Patient 12). (Refer to L 668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on interview and record review, the Hospice Agency (HA) failed to ensure there was a contract with their appointed Medical Director (MD1) for eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This failure resulted in patients not having physician oversite. --- A review of HAs undated form titled ";Organizational Chart", indicated Medical Doctor 1 (MD1) and Medical Doctor 2 (MD2) were listed as their ";Medical Director". During an interview on 4/29/2024 at 9:43 a.m. with the Administrator (ADM), an entrance conference was conducted with the ADM. During the entrance conference the ADM stated MD1 was the HAs Medical Director and MD2 was another physician employed. During an interview on 4/29/2024 at 11:15 a.m. with the ADM, the ADM stated the Medical Directors contract was taken by Entity 1 (EN1) in March 2024. During a telephone interview on 5/2/2024 at 10:48 a.m. with MD1, MD1 stated he started working as the medical director for the HA in February 2024. MD1 stated he has not logged into the HA's EMR system. MD1 stated he dictates his notes on a WORD document then sends them via email to the HA. MD1 stated he sees and certified patients for hospice care but that he has not signed any patients CTI. During a telephone interview on 5/3/2024 at 11:35 a.m. with MD2, MD2 stated he does not have a contract with the HA. MD2 stated he has not treated any patients from the HA. During a telephone interview on 5/4/2024 at 11:55 a.m. with MD3, MD3 stated he was the medical director for the HA up until January or February 2024. MD3 stated he did not treat or see HAs patients in March, April, or May of 2024. 1.A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). Further review of the record indicated MD 2 was the attending doctor. 2. A review of Patient 2s medical record form titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). The form also indicated MD2 was Patient 2's attending physician. 3. A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). Further review of the record indicated MD 2 was the attending doctor. 4. A review of Patient 4s medical record form titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease without heart failure. The form also indicated MD2 was Patient 4s attending physician. 5. A review of Patient 5s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/7/2024" with a hospice diagnosis of end stage heart failure (heart unable to pump adequately, shortness of breath, fatigue, and irregular heartbeat even while at rest). 6. A review of Patient 7s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/9/2024" with a hospice diagnosis of hypertensive heart disease without heart failure. A review of Patient 7s medical record form titled ";Certification of Terminal Illness" dated 1/9/2024 to 3/8/2024, indicated MD3 was listed as his hospice physician. The form indicated it was not signed by MD3. 7. A review of Patient 8s medical record form titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease without heart failure. The form also indicated MD1 was listed as the ";Attending Physician" and MD2 was listed as the ";Hospice Physician". 8. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). Further review of the record indicated MD 2 was the attending doctor. 9. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). Further review of the record indicated MD 2 was the attending doctor. 10. A review of Patient 11s medical record form titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease with heart failure. The form also indicated MD2 was listed as the hospice and attending physician. 11. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). A review of Patient 12s ";Certification of Terminal Illness", for certification period 1/9/2024 to 4/7/2024, indicated a narrative was written and the hospice doctor's name was MD 3. The record was not signed. A review of Patient 12s ";Certification of Terminal Illness", for certification period 4/8/2024 to 7/6/2024, indicated a narrative was written and the hospice doctor's name was MD 1. The section titled, ";Hospice Physician Signature" and ";Date" were blank. A review of the HAs policy and procedure titled, ";Hospice Contracted Services", dated April 2020, indicated, ";Policy: Senior management will be responsible for the availability of care and services to meet the needs of the patients served...These contracted services will be defined by a written agreement, before individuals from that source will be permitted to provide services on behalf of the organization." A review of the HAs policy and procedure titled, ";Scope of Services", dated April 2020, indicated, ";Policy: HA provides hospice services that are intended to meet the physical, psychosocial, practical, and spiritual needs of patients and families/caregivers...core hospice services provided by...physicians...are available 24 hours a day, seven (7) days a week...3. An interdisciplinary group of professionals and volunteers will develop with each patient and family/caregiver a plan of care, which include, as appropriate, the following services: A. Physician."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial certifications for twelve of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) to support diagnosis of the patient's terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The agency failed to: Ensure there was a physicians signature and documentation of clinical information that included patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice care and services. This failure resulted in the hospice medical director and/or the designee certified patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses. It also resulted in patients not being certified by a medical doctor for hospice care, which can result lack and inappropriate care provided to the patients. --- During an interview on 4/30/2024 at 12:55 p.m. with Director of Nurses Designee (DD), DD stated physician complete patients Certification of Terminal Illness (CTI) in the HAs Electronic Medical Record (EMR) initially and at every recertification. DD stated CTIs are important to be able to follow physician orders because the HA was under their supervision. During a telephone interview on 5/2/2024 at 10:48 a.m. with MD1, MD1 stated he started working as the medical director for the HA in February 2024. MD1 stated he has not logged into the HAs EMR system. MD1 stated he dictates his notes on a WORD document then sends them via email to the HA. MD1 stated he sees and certified patients for hospice care but that he has not signed any patients CTI. During a telephone interview on 5/3/2024 at 11:03 a.m. with MD2, MD2 stated he wrote patient notes in a notebook and then emailed a photograph of his notes to the HA. MD2 stated after emailing a photograph of patients' notes that would be the end of his process. MD2 stated he did not document any notes in the HAs EMR system. During a telephone interview on 5/3/2024 at 11:35 a.m. with MD2, MD2 stated he does not have a contract with the HA. MD2 stated he has not treated any patients from the HA. During a telephone interview on 5/4/2024 at 11:55 a.m. with MD3, MD3 stated he was the medical director for the HA up until January or February 2024. MD3 stated he did not treat or see HAs patients in March, April, or May of 2024. 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During a concurrent interview and record review on 5/2/2024, at 1:30 p.m., the Director of Nurses Designee (DD) reviewed Patient 1s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/5/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. The areas not assessed were: Patient 1s height, weight, genitourinary (bladder, kidneys, urine) system, reproductive system, activities of daily living, and imminence of death. DD continued to review the record and stated Patient 1 had not been assessed for his psychosocial status, spiritual assessment, and need for volunteer services. The areas ";Additional Nursing Observation", ";Skilled Care/Services Provided", ";Coordination of Care", ";Equipment/Supplies", ";The following are discussed with the patient and/or caregiver prior to provision of care", ";Plan of Care", ";Patient/Representative Instructions", ";Eligibility Assessment as Evidenced by", ";Teaching", and ";Need for Comprehensive Assessment" were left blank. A record review of Patient 1s document titled, ";Initial Orders and Plan of Care", dated 1/5/2024, did not indicate a plan of care was formulated. A record review of Patient 1s document titled, ";Certification of Terminal Illness", for certification period 1/5/2024 to 4/3/2024, indicated, ";I have reviewed and agree with the Plan of care that includes Initial Orders and Plan of Care, Medication Profile and Plan of Care Problems (identified in assessments) and admission to hospice." Further review of the record indicated Medical Director 2 (MD 2)s name. The record was not signed. During an interview on 5/3/2024, at 11:25 a.m. MD 2 stated he did not have any medical notes for Patient 1. MD 2 stated he had not seen and examined Patient 1. 2. A review of Patient 2s medical record form titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). The form also indicated MD2 was Patient 2's attending physician. A review of Patient 2s medical record form titled ";Certification of Terminal Illness" dated 1/5/2024 to 3/4/2024, indicated MD3 was listed as her hospice physician. The form also indicated MD2 was listed as her attending physician. Lastly, the form indicated it was not signed by MD2 or MD3. A review of Patient 2s medical record form titled ";Initial Orders and Plan of Care" dated 1/5/2024, indicated MD3 was listed as the ";Hospice Physician" and MD2 as the ";Attending Physician". The form also indicated it was not signed by MD3 or MD2. During a concurrent interview and record review on 4/30/2024 at 3:37 p.m. with the Director of Nurses Designee (DD) of Patient 2s EMR, DD stated both of Patient 2s CTIs were not signed. DD stated there was no document (CTI) uploaded into Patient 2s EMR. During a telephone interview on 5/2/2024 at 11:10 a.m. with MD1, MD1 stated he attempted to see Patient 2 on March 9, 2024, but Patient 2 was not home. MD1 stated he did not recall certifying Patient 2 for hospice services. MD1 stated, ";I dont know anything about her." During a telephone interview on 5/3/2024 at 11:14 a.m. with MD2, MD2 stated he did not have any recollection of seeing Patient 2. MD2 stated he did not have written notes for Patient 2. 3. A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). During a record review on 4/29/2024, at 1:20 p.m., Patient 3s record did not have a comprehensive assessment by the nurse for the current admission. During an interview on 5/2/2024, at 1:30 p.m., DD stated an ";e-sign" (an electronic signature) on a document indicated it was authenticated/signed. During a concurrent interview and record review on 5/2/2024, at 1:34 p.m., the DD reviewed Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/12/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. The areas not assessed were: vital signs to include blood pressure, temperature, pulse, respiratory rate; current weight; functional limitation, activities permitted, mental status, memory recall, and skin. Further review of the record indicated, ";Need for Comprehensive Assessment", there was a check mark placed on ";Social Work" and ";Spiritual Care". A review of Patient 3s document titled, ";Initial Orders and Plan of Care", dated 4/25/2024, did not indicate a plan of care was formulated. A review of Patient 3s document titled, ";Certification of Terminal Illness", for certification period 4/25/2024 to 6/23/2024, indicated, ";I have reviewed and agree with the Plan of care that includes Initial Orders and Plan of Care, Medication Profile and Plan of Care Problems (identified in assessments) and admission to hospice." Further review of the record indicated MD 2s name. The record was not signed because it did not indicate ";e-sign". During an interview on 5/3/2024, at 11:26 a.m. MD 2 stated he did not have any medical notes on Patient 3. MD 2 stated he had not seen and examined Patient 3. 4. A review of Patient 4s medical record form titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease without heart failure. The form also indicated MD2 was Patient 4s attending physician. A review of Patient 4s medical record form titled ";Certification of Terminal Illness" dated 3/1/2024 to 5/29/2024, indicated MD1 was listed as Patient 4's hospice and attending physician. The form also indicated it was not signed by MD1. A review of Patient 4s medical record form titled ";Physician Order Details" dated 3/1/2024, indicated MD3 was listed under ";Physician". The form also indicated it was not signed by MD3. During an interview on 5/1/2024 at 11:15 a.m. with Patient 4s Caretaker 1 (CT1), CT1 stated Patient 4 was diabetic (high blood sugar) and needed medication for his condition. CT1 stated he requested a doctors home visit a month ago to the wound nurse that saw Patient 4 on Mondays. During a telephone interview on 5/2/2024 at 11:13 a.m. with MD1, MD1 stated he did not dictate notes for Patient 4. MD1 stated he did not recall writing a CTI for Patient 4. During a telephone interview on 5/3/2024 at 11:18 a.m. with MD2, MD2 stated he did not have any notes for Patient 4. MD2 stated he had not seen Patient 4. 5. A review of Patient 5s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/7/2024" with a hospice diagnosis of end stage heart failure (heart unable to pump adequately, shortness of breath, fatigue, and irregular heartbeat even while at rest). A review of Patient 5s medical record form titled ";Certification of Terminal Illness" dated 1/7/2024 to 3/6/2024, indicated MD3 was listed as Patient 5's hospice physician. The form also indicated MD2 was listed as her attending physician. Lastly, the form indicated it was not signed by MD2 or MD3. 6. A review of Patient 6s medical record form titled ";Initial Orders and Plan of Care", indicated a start of care date on 1/22/2024 with a primary diagnosis of hypertensive heart disease without heart failure. A review of Patient 6s medical record form titled ";Certification of Terminal Illness" dated 1/22/2024 to 3/21/2024, indicated MD3 was listed as Patient 6's hospice and attending physician. The form also indicated ";Date of Verbal Certification: 03/21/2024". Lastly, the form indicated it was not signed by MD3. A review of Patient 6s medical record form titled ";Initial Orders and Plan of Care" dated 1/22/2024, indicated MD3 was listed as the attending and hospice physician. The form also indicated it was not signed by MD3. 7. A review of Patient 7s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/9/2024" with a hospice diagnosis of hypertensive heart disease without heart failure. A review of Patient 7s medical record form titled ";Certification of Terminal Illness" dated 1/9/2024 to 3/8/2024, indicated MD3 was listed as Patient 7's hospice physician. The form indicated it was not signed by MD3. A review of Patient 7s medical record form titled ";Initial Orders and Plan of Care" dated 1/9/2024, indicated MD3 was listed as the ";Hospice Physician". The form also indicated it was not signed by MD3. 8. A review of Patient 8s medical record form titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease without heart failure. The form also indicated MD1 was listed as the ";Attending Physician" and MD2 was listed as the ";Hospice Physician". A review of Patient 8s medical record form titled ";Certification of Terminal Illness" dated 4/25/2024 to 6/23/2024, indicated MD1 was listed as Patient 8's hospice and attending physician. The form indicated it was not signed by MD1. A review of Patient 8s medical record form titled ";Physician Order Details" dated 4/24/2024, indicated ";Refer to hospice care for evaluation and admission". The form also indicated MD1 was listed as the ";Physician". During a concurrent interview and record review on 4/30/2024 at 3:48 p.m. with the DD of Patient 8s EMR, DD stated Patient 8s CTI is not signed by a physician. During a telephone interview on 5/2/2024 at 11:15 a.m. with MD1, MD1 stated he did not have any records for Patient 8. MD1 stated he did not treat Patient 8. During a telephone interview on 5/3/2024 at 11:23 a.m. with MD2, MD2 stated she has no records for Patient 8. MD2 stated he did not see Patient 8. 9. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an interview at the home visit on 4/30/2024, at 9:55 a.m. Registered Nurse 1 (RN 1) stated Patient 9 had heart failure, diabetes (elevated levels of sugar in the blood), and high blood pressure. During an observation of the home visit on 4/30/2024, at 10:00 a.m. Patient 9 was sitting in a chair in the living room, covered in a blanket. Patient 9 was not using oxygen. During an interview at the home visit on 4/30/2024, at 10:10 a.m., RN 1 assessed Patient 9s oxygen saturation reading (a percentage to measure how much blood is flowing in the body). RN 1 stated the reading was 95% in room air (without the use of oxygen, using ambient air to breathe). During an observation of the home visit on 4/30/2024, at 10:10 a.m., RN 1 assisted Patient 9 to stand up from the chair. Patient 9 stood up and sat down with RN 1 assisting. During the period of standing to sitting, Patient 9s breathing pattern was unlabored, and no use of oxygen occurred. During an observation of the home visit on 4/30/2024, at 10:17 a.m., RN 2 assessed patient 9s arms and legs. RN 1 stated Patient 9 did not have edema (swelling) on either of the arms and legs. During an interview and record review on 4/30/2024, at 10:45 a.m., Patient 9s second caregiver (CG 2) stated she wrote all the visits Patient 9 has received in a notebook. The notebook indicated Patient 9 received visits from the MD 1 on 4/10/2024. During a concurrent interview and record review on 5/2/2024, at 11:14 a.m., DD reviewed Patient 9s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 3/27/2024. DD stated the assessment focused on the heart failure. Further review of the record indicated, Patient 9s qualifying criteria included an NYHA (New York Heart Association classification of heart failure) level 4 (the highest level of heart failure. Patient has symptoms at rest. If any physical activity is undertaken, physical discomfort increased). A review of Patient 9s document titled, ";Initial Orders and Plan of Care", dated 3/27/2024, did not indicate a plan of care was formulated. During an interview on 5/2/2024, at 10:53 a.m., MD 1 stated that Patients with NYHA 4 are unable to walk more than five steps without being more than short of breath. If patients had right sided heart failure, he would expect edema. Patients with heart failure would benefit from continuous oxygen. A review of Patient 9s document titled, ";Certification of Terminal Illness", for certification period 3/27/2024 to 6/24/2024, indicated, ";I have reviewed and agree with the Plan of care that includes Initial Orders and Plan of Care, Medication Profile and Plan of Care Problems (identified in assessments) and admission to hospice." Further review of the record indicated MD 2s name, not MD 1. The record was not signed because it did not indicate ";e-sign". 10. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A review of Patient 10s ";Certification of Terminal Illness", for certification period 1/2/2024 to 3/31/2024, indicated a narrative was written and the hospice doctors name was MD 3. The record was not signed. 11. A review of Patient 11s medical record form titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease with heart failure (heart not pumping blood properly). The form also indicated MD2 was listed as the hospice and attending physician. A review of Patient 11s medical record form titled ";Certification of Terminal Illness" dated 2/27/2024 to 4/26/2024, indicated MD1 was listed as Patient 11's hospice and attending physician. The form indicated it was not signed by MD1. A review of Patient 11s medical record form titled ";Initial Orders and Plan of Care" dated 2/27/2024, indicated MD2 was listed as the hospice and attending physician. The form also indicated it was not signed by MD2. During a concurrent interview and record review on 4/30/2024 at 3:53 p.m. with the DD of Patient 11s EMR, DD stated Patient 11s CTI was not signed. During a telephone interview on 5/2/2024 at 11:16 a.m. with MD1, MD1 stated he did not certify Patient 11 for hospice services. MD1 stated Patient 11 did not meet hospice criteria. During a telephone interview on 5/3/2024 at 11:23 a.m. with MD2, MD2 stated he did not treat Patient 11. 12. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). A review of Patient 12s ";Certification of Terminal Illness", for certification period 1/9/2024 to 4/7/2024, indicated a narrative was written and the hospice doctors name was MD 3. The record was not signed. A review of the HAs policy and procedure titled, ";Certification of Terminal Illness", dated April 2020, indicated, ";Procedure: 1. At the time of admission to hospice, the hospice Medical Director or the patients attending physician will complete a certification narrative that reflects the patients individual circumstances...(The hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms.)...3. 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...4. Both the attending physicians and Medical Directors signed and dated initial certification forms must be on file prior to billing the first claim."

Based on interview and record review, the Hospice Agency (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 six of fourteen sampled patients (Patient 1, Patient 2, Patient 7, Patient 10, Patient 11, and Patient 12). This failure resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- A review of HAs undated form titled ";Organizational Chart", indicated Medical Doctor 1 (MD1) and Medical Doctor 2 (MD2) were listed as their ";Medical Director". During an interview on 4/29/2024 at 9:43 a.m. with the Administrator (ADM), ADM provided an entrance conference. During the entrance conference the ADM stated MD1 was the HAs Medical Director and MD2 was another physician employed. During an interview on 4/30/2024 at 12:55 p.m. with Director of Nurses Designee (DD), DD stated physician complete patients Certification of Terminal Illness (CTI) in the HAs Electronic Medical Record (EMR) initially and at every recertification. DD stated CTIs are important to be able to follow physician orders because the HA was under their supervision. During a concurrent interview and record review on 4/30/2024 at 3:30 p.m. with the DD of the HA's EMR, DD stated if the CTI form does not indicate ";E-signed" it meant it was not signed. DD stated the arrow next to the physicians name is used to upload documents. During a telephone interview on 5/2/2024 at 10:48 a.m. with MD1, MD1 stated he was started working as the medical director for the HA in February 2024. MD1 stated he has not logged into the HAs EMR system. MD1 stated he dictates his notes on a WORD document then sends them via email to the HA. MD1 stated he sees and certified patients for hospice care but that he has not signed any patients CTI. During a telephone interview on 5/3/2024 at 11:03 a.m. with MD2, MD2 stated he wrote patient notes in a notebook and then emailed a photograph of his notes to the HA. MD2 stated after emailing a photograph of patients notes that would be the end of his process. MD2 stated he did not document any notes in the HAs EMR system. During a telephone interview on 5/4/2024 at 11:55 a.m. with MD3, MD3 stated he was the medical director for the HA up until January or February 2024. MD3 stated he did not treat or see HAs patients in March, April, or May of 2024. 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). A review of Patient 1s record titled, ";Certification of Terminal Illness", for certification period 4/4/2024 to 7/2/2024, indicated a narrative was written and the hospice doctors name was MD 2. The section titled, ";Hospice Physician Signature" and ";Date" were blank. During an interview on 5/3/2024, at 11:25 a.m. MD 2 stated he had not seen and examined Patient 1. 2. A review of Patient 2s medical record form titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). The form also indicated MD2 was Patient 2's attending physician. A review of Patient 2s medical record form titled ";Certification of Terminal Illness" dated 3/5/2024 to 5/3/2024, indicated MD2 was listed as Patient 2's hospice physician. The form also indicated it was not signed by MD2. During a concurrent interview and record review on 4/30/2024 at 3:37 p.m. with the Director of Nurses Designee (DD) of Patient 2s EMR, DD stated both of Patient 2s CTIs were not signed. DD stated there was no document (CTI) uploaded into Patient 2s EMR. During a telephone interview on 5/2/2024 at 11:10 a.m. with MD1, MD1 stated he attempted to see Patient 2 on March 9, 2024, but Patient 2 was not home. MD1 stated he did not recall certifying Patient 2 for hospice services. MD1 stated, ";I dont know anything about her." During a telephone interview on 5/3/2024 at 11:14 a.m. with MD2, MD2 stated he did not have any recollection of seeing Patient 2. MD2 stated he did not have written notes for Patient 2. 3. A review of Patient 7s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/9/2024" with a hospice diagnosis of hypertensive heart disease without heart failure. A review of Patient 7s medical record form titled ";Certification of Terminal Illness" dated 3/6/2024, indicated there was no listed physicians name. A review of Patient 7s medical record form titled ";End of Care Summary" dated 4/1/2024, did not indicate Patient 7s reason for discharge. The form also indicated MD2 was listed under ";Physician". Lastly, the form indicated it was not signed by MD2. During a telephone interview on 5/2/2024 at 11:22 a.m. with MD1, MD1 stated he did not treat Patient 7. During a telephone interview on 5/3/2024 at 11:22 a.m. with MD2, MD2 stated he did not treat Patient 7. 4. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A review of Patient 10s ";Certification of Terminal Illness", for certification period 4/1/2024 to 6/29/2024, indicated a narrative was written and the hospice doctors name was MD 2. The section titled, ";Hospice Physician Signature" and ";Date" were blank. 5. A review of Patient 11s medical record form titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease with heart failure. The form also indicated MD2 was listed as the hospice and attending physician. A review of Patient 11s medical record form titled ";Certification of Terminal Illness" dated 4/27/2024, indicated MD1 was listed as Patient 11's hospice physician. The form also indicated it was not signed by MD1. During a review of Patient 11s medical record form titled ";Physician Order Details" dated 4/18/2024, indicated ";Recertify patient... under routine care for the 6th benefit period starting 4/27/2024 to 6/25/2024...". The form also indicated MD1 was listed as the ";Physician". Lastly, the form was not signed by MD1. During a concurrent interview and record review on 4/30/2024 at 3:53 p.m. with the DD of Patient 11s EMR, DD stated Patient 11s CTI was not signed. During a telephone interview on 5/2/2024 at 11:16 a.m. with MD1, MD1 stated he did not certify Patient 11 for hospice services. MD1 stated Patient 11 did not meet hospice criteria. During a telephone interview on 5/3/2024 at 11:23 a.m. with MD2, MD2 stated he did not treat Patient 11. 6. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). A review of Patient 12s ";Certification of Terminal Illness", for certification period 4/8/2024 to 7/6/2024, indicated a narrative was written and the hospice doctors name was MD 1. The section titled, ";Hospice Physician Signature" and ";Date" were blank. A review of the HAs policy and procedure titled, ";Certification of Terminal Illness", dated April 2020, indicated, ";Procedure...5. A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patients medical record or, if applicable, examination of the patient."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation on Clinical Records was met as follows: --- On 5/3/2024 at 11:07 a.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was identified in the presence of the facilitys Director of Nurses Designee (DD). The HA failed to ensure the clinical records for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) included the plan of care, initial assessment, comprehensive assessments, and clinical notes that reflected the patients current health status, correct and updated assessments. (Refer to L672). The cumulative effect of these systemic practices resulted in Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12 did not have completed clinical records that could potentially not identify a change in patients conditions and affect the patients care and services that could lead to hospitalization and death when clinical records did not include current, correct, and updated comprehensive assessments of the patients. 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 are safeguarded from unauthorized access by any individuals or hospice staff.

Based on interview and record review the Hospice Agency (HA) failed to: Ensure the clinical records for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) included the plan of care, initial assessment, comprehensive assessments, and clinical notes that reflected the patients current health status, correct and updated assessments. The cumulative effect of these systemic practices resulted in Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12 did not have completed clinical records that could potentially not identify a change in patients conditions and affect the patients care and services that could lead to hospitalization and death when clinical records did not include current, correct and updated comprehensive assessments of the patients. On 5/3/2024 at 11:07 a.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called in the presence of the agency's Director of Nurses Designee (DD), related to failure of HA to ensure to maintain complete clinical records for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). As a result, the non-compliance resulted in incomplete clinical records that does not reflect patients' current condition and needs which likely to cause unidentified needs, serious injury, harm, impairment, or death to a patient. --- 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During a concurrent interview and record review on 5/2/2024, at 1:30 p.m., the Director of Nurses Designee (DD) reviewed Patient 1s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/5/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. The record further indicated the document was not signed. DD stated indication of a signed document would be ";e-signed". During an interview on 5/2/2024, at 11:14 a.m., DD stated the comprehensive assessment was a system assessment that is used to formulate the plan of care for the patient. A record review of Patient 1s document titled, ";Initial Orders and Plan of Care", dated 1/5/2024, did not indicate a plan of care was formulated. 2. A review of Patient 2s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 2s home, Patient 2 was not at home. LVN2 stated she has not seen Patient 2 since March. LVN2 stated Patient 2s Caretaker 1 (CT1) informed her that Patient 2 had left the home on 4/16/2024. LVN2 stated she did not document anything regarding Patient 2s status in the HAs EMR system. LVN2 stated she did not know if the physician was aware of Patient 2s status. LVN2 stated Patient 2 did not have a plan of care. During a review of Patient 2s EMR, the EMR indicated there was one documented plan of care for Patient 2 dated 1/5/2024. Patient 2s EMR form titled ";IDT plan of care and review of comprehensive assessment" dated 1/5/2024, 3/8/2024, 3/22/2024, and 4/5/2024, indicated the following sections were left blank ";Hospice Physician; Co-morbid Diagnosis; Physician Report; Spiritual Care Report; SW Report; Volunteer Report; and Eligibility Assessment – Current Numbers." All forms did not indicate any HAs staff signatures. 3. A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). During a record review on 4/29/2024, at 1:20 p.m., Patient 3s record did not have a comprehensive assessment by the nurse. During a concurrent interview and record review on 5/2/2024, at 1:34 p.m., the DD reviewed Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 1/12/2024. The DD stated the record was incomplete because there were areas left blank, meaning the patient was not assessed for that area. During an interview and record review on 5/4/2024, at 11:50 a.m., DD submitted Patient 3s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 4/25/2024. DD stated she had given the surveyor the initial nursing assessment from another certification period. DD provided document titled, ";Document History", printed on 5/4/2024 and indicated the assessment record was created on 4/30/2024, day 2 of the survey. A record review of Patient 3s document titled, ";Initial Orders and Plan of Care", dated 4/25/2024, did not indicate a plan of care was formulated. 4. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form untitled, indicated ";Initial Nursing Assessment Initiated 3/1/2024"; Certification period from 3/1/2024 to 5/29/2024. The following sections were left blank: POLST signed; Advance Directive; Allergies; and Co-morbidities Surgery dates. During a review on 4/29/2024 at 1:23 p.m. of Patient 4s Electronic Medical Record (EMR) medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated the form was left blank. The form also indicted the signature sections for Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) were left blank. During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 4s home, LVN2 stated she did not have Patient 4s individualized plan of care. LVN2 stated she provided Patient 4s care by following the admitting nurse verbal instructions. Patient 4 stated he had cholesterol, diabetes, and a wound on top of his head. LVN2 stated she was not aware Patient 4 had diabetes mellitus. During an interview on 5/1/2024 at 11:15 a.m. with Patient 4s Caretaker 1 (CT1), CT1 stated a Nurse Practitioner sees Patient 4 on Mondays. CT1 stated he has told and ask the Nurse Practitioner about Patient 4s diabetes medication and monitoring machine. CT1 stated Nurse Practitioner has told him that he will inform a doctor, but the doctor has not seen Patient 4. During a concurrent interview and record review on 5/2/2024 at 11:13 a.m. with Medical Director 1 (MD1) of Patient 4s clinical notes, MD1 stated he did not dictate any notes for Patient 4. During a concurrent interview and record review on 5/2/2024 at 1:35 p.m. with DD of Patient 4s EMR, DD stated Patient 4 did not have a plan of care. DD stated Patient 4 needed to have a plan of care. 5. A review of Patient 8s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 8s medical record form untitled, indicated ";Initial Nursing Assessment Initiated 4/25/2024" form indicated it was not complete. The following areas were not assessed vital signs to include blood pressure, temperature, pulse, respiratory rate; current weight; functional limitation, activities permitted, mental status, memory recall, skin, musculoskeletal, sensory, cardiovascular, gastrointestinal, pain assessment, respiratory, endocrine, nutrition/hydration, genitourinary, reproductive, additional assessment, activity of daily living, psychosocial assessment, spiritual assessment, skilled care/Services provided, coordination of care, equipment/supplies, plan of care, eligibility assessment, teaching, need for comprehensive assessment, attending physician, and summary/plan/support diagnosis. During a concurrent interview and record review on 4/30/2024 at 3:15 p.m. with the DD of Patient 8s EMR, DD stated Patient 8s start of care date was 4/25/2024. DD stated she was unable to locate an initial nursing assessment for Patient 8 that was supposed to be completed by 4/25/2024. DD stated Patient 8 did not have a documented plan of care. During a review of Patient 8s medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 4/26/2024, indicated there were no signatures in sections Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) were left blank. The form also indicated Medical Doctor 1 (MD1) and MD2s names were printed in section ";Physician Name, Signature, Date". During a concurrent interview and record review on 5/2/2024 at 10:48 a.m. with Medical Director 1 (MD1) of Patient 8s clinical notes, MD1 stated he did not have any notes for Patient 8. During a concurrent interview and record review on 5/3/2024 at 11:23 a.m. with Medical Director 2 (MD2) of Patient 8s clinical notes, MD2 stated he did not have any records for Patient 8. MD2 stated he did not see Patient 8. 6. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During a concurrent interview and record review on 4/20/2024, at 9:59 a.m., RN 1 reviewed the surveyors Patient 9s record titled, ";Initial Orders and Plan of Care", for certification period 3/27/2024 to 6/24/2024. RN 1 stated the record did not have any interventions and goals written on it. During an interview on 5/2/2024, at 11:04 a.m., Medical Director 1 (MD 1) stated he was aware Patient 9 had diabetes. MD 1 stated he was not aware Patient 9 did not have a POC. MD 1 stated the importance of having a POC was to follow standard regiment for each disease. Whoever is doing care, they can follow along and see what the progress is. MD 1 stated the risk of not having a POC is not knowing what is going on with the patient. That would be the whole purpose of the whole medical team, to know what is happening with the patient. During a concurrent interview and record review on 5/2/2024, at 11:14 a.m., DD reviewed Patient 9s record titled, ";A0245. Date Initial Nursing Assessment Initiated", dated 3/27/2024. DD reviewed section ";Endocrine" and stated the record indicated ";WNL" (within normal limits). DD stated the record should have had a narrative about diabetes to include blood sugar levels. DD stated the system assessment was important because that is what was used to formulate the plan of care for the patient. A record review of Patient 9s document titled, ";Initial Orders and Plan of Care", dated 3/27/2024, did not indicate a plan of care was formulated. 7. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A review of Patient 10s document titled, ";Initial Orders and Plan of Care", dated 1/2/2024, did not indicate a plan of care was formulated. 8. A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). A review of Patient 11s document titled, ";Initial Orders and Plan of Care", dated 2/27/2024, did not indicate a plan of care was formulated. During a concurrent interview and record review on 5/2/2024 at 11:16 a.m. with Medical Director 1 (MD1) of Patient 11s clinical notes, MD1 stated Patient 11 did not meet hospice criteria and did not admit her to hospice care. During a concurrent interview and record review on 5/3/2024 at 11:23 a.m. with Medical Director 2 (MD2) of Patient 11s clinical notes, MD2 stated he did not see Patient 11. 9. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). A review of Patient 12s document titled, ";Initial Orders and Plan of Care", dated 1/9/2024, did not indicate a plan of care was formulated. A review of the HAs policy and procedure titled, ";The Plan of Care", dated April 2020, indicated, ";Procedure...4. The plan of care will identify the patients needs and services...It must state in detail, the scope and frequency of services needed to meet the patients and family/caregivers needs, goals and outcome achievement." A review of the HAs policy and procedure titled, ";Interdisciplinary Group Plan of Care", dated April 2020, indicated, ";Procedure...16...clinical notes will be submitted to the patients permanent clinical record." A review of the HAs policy and procedure titled, ";Comprehensive Assessment", dated April 2020, indicated, ";Procedure 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented..." A review of the HAs policy and procedure titled, ";Hospice Nursing Care", dated April 2020, indicated, ";Procedure...3. The hospice nurse will...G. Prepare clinical and progress notes that demonstrate progress toward established goals." A review of the HAs policy and procedure titled, ";Contents of the Clinical Record", dated April 2020, indicated, ";Procedure...2. Documentation will include...M. Signed and dated clinical notes." ..

Based on interview and record review the Hospice Agency (HA) failed to ensure fourteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) had signed notice of patient rights in their medical records. This failure resulted in an incomplete medical record, and it had the potential to result in patient and their family/caregiver is not aware of the right they have as patients. --- 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). During an observation on 4/29/2024, at 9:15 a.m., the business location indicated the agency was operating inside a room in a dentist clinic. Outside the dentist practice was no signage of the agency. Inside the dentist clinic, there was a paper posted in the receptionist area indicating the agency to be in suite ";c". Suite ";C" was in the back corner of the dentist clinic. The room did not have any computers, phones, printers, file cabinets, and patient records. 2. A review of Patient 2s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). 3. A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). 4. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). 5. A review of Patient 5s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/7/2024" with a hospice diagnosis of end stage heart failure (heart unable to pump adequately, shortness of breath, fatigue, and irregular heartbeat even while at rest). 6. A review of Patient 6s medical record form titled ";Initial Orders and Plan of Care", indicated a start of care date on 1/22/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). 7. A review of Patient 7s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/9/2024" with a hospice diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). 8. A review of Patient 8s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). 9. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an observation of the home visit on 4/30/2024, at 10:15 a.m., the contents of Patient 9s agency folder were reviewed. The folder contained blank forms. There was no evidence Patient 9 had received information about her rights. During a concurrent interview and record review, at the home visit on 4/30/2024, at 10:57 a.m., Registered Nurse 1 (RN 1) stated there was no copies of admission consents and patient rights in the folder. RN 1 asked Patient 9s family about consents received. Patient 9s family provided to RN 1 carbon copies of documents titled, ";Rosewood Hospice & Palliative Care, Inc.". RN 1 stated the documents indicated Patient 9 had signed them on 12/28/2023. Further review of the records, indicated, start of care ";12/28/2023". During an interview on 5/2/2024, at 11:45 a.m., the Director of Nurses designee (DD) stated the copies of the consents Patient 9 had, were from her previous hospice admission. DD stated, Patient 9s start of care was a new admission and required new consents to be signed. The consents were the patients signature that indicated patient was provided with information about her rights. DD stated it was important for Patient 9 and family to have information about their rights because they are authorizing the HA to care for them. They should be aware of their rights. 10. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). 11. A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). 12. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). 13. A review of Patient 13s record titled ";Bright and White Hospice", indicated a start of care date on 1/2/2024, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). 14. A review of Patient 14s record titled, ";Bright and White Hospice", indicated a start of care date on 1/2/2024, with a primary diagnosis of hypertensive heart disease without heart failure. During an interview on 4/29/2024 at 9:43 a.m. with the Administrator (ADM), the ADM stated patients medical records were stored on their Electronic Medical Record (EMR) system. During an interview on 4/29/2024 at 11:15 a.m. with the ADM, the ADM stated the HAs physical medical records were confiscated by Entity 1 (EN1) in March 2024. During a concurrent interview and record review on 4/30/2024 at 3:53 p.m. with the Director of Nurses Designee (DD) of the HAs EMR system, DD stated she was not able to locate patients signed noticed of patients rights. DD stated patients ";paper" records were taken in March. DD stated consents demonstrate patient knowledge and consent to receive hospice services. A record review of the HAs policy and procedure titled, ";Contents of Clinical Record", dated April 2020, indicated, ";Procedure: 1. The following will be available in the clinical record as applicable to care and services provided...B. Consent and authorization forms...2. Documentation will include...B. Signed copy of the notice of patient rights and other documents for protected health information."

Based on interview and record review the Hospice Agency (HA) failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for ten fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This failure had the potential to result in inaccurate patient information or assessment will be entered in the patients clinical record that could affect the patients quality of care and well-being. --- During an interview on 4/29/2024 at 11:15 a.m. with the ADM, the ADM stated the patients physical medical records were confiscated by Entity 1 (EN1) in March 2024. During a concurrent interview and record review on 5/2/2024 at 1:35 p.m. with the Director of Nurses Designee (DD), DD stated patients documents need to be uploaded in their Electronic Medical Record (EMR) system for all to see. 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). A review of Patient 1s record titled, ";Certification of Terminal Illness", for certification period 1/5/2024-4/3/2024, indicated a narrative was written and the hospice doctors name was MD 2. The record was not signed. A review of Patient 1s record titled, ";Certification of Terminal Illness", for certification period 4/4/2024 -7/2/2024, indicated a narrative was written and the hospice doctors name was MD 2. The section titled, ";Hospice Physician Signature" and ";Date" were blank. During an interview on 5/3/2024, at 11:25 a.m. MD 2 stated he had not seen and examined Patient 1. 2. A review of Patient 2s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 2s home, Patient 2 was not at home. LVN2 stated she has not seen Patient 2 since March. LVN2 stated Patient 2s Caretaker 1 (CT1) informed her that Patient 2 had left the home on 4/16/2024. LVN2 stated she did not document anything regarding Patient 2s status in the HAs EMR system. LVN2 stated Patient 2 did not have a plan of care. During a concurrent interview and record review on 5/2/2024 at 12:04 p.m. with the DD of Patient 2s EMR, DD stated there was nothing documented about Patient 2 leaving the board and care. During a review of Patient 2s EMR, the EMR indicated there was one documented plan of care for Patient 2 dated 1/5/2024. Patient 2s EMR form titled ";IDT plan of care and review of comprehensive assessment" dated 1/5/2024, 3/8/2024, 3/22/2024, and 4/5/2024, indicated the following sections were left blank ";Hospice Physician; Co-morbid Diagnosis; Physician Report; Spiritual Care Report; SW Report; Volunteer Report; and Eligibility Assessment – Current Numbers." All forms did not indicate any HAs staff signatures. 3. A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). A record review of Patient 3s record titled, ";Certification of Terminal Illness", for certification period 4/25/2024-6/23/2024, indicated a narrative was written and the hospice doctors name was MD 2. The record was not signed. During an interview on 5/3/2024, at 11:26 a.m. MD 2 stated he had not seen and examined Patient 3. 4. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form untitled, indicated ";Initial Nursing Assessment Initiated 3/1/2024"; Certification period from 3/1/2024 to 5/29/2024. The following sections were left blank: POLST signed; Advance Directive; Allergies; and Co-morbidities Surgery dates. During a review on 4/29/2024 at 1:23 p.m. of Patient 4s EMR medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated the form was left blank. The form also indicted the signature sections for Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) were left blank. During a joint home visit on 5/1/2024 at 11:15 a.m. with License Vocational Nurse 2 (LVN2) to Patient 4s home, LVN2 stated did not have Patient 4s individualized plan of care. LVN2 stated she provided Patient 4s care by following the admitting nurse verbal instructions. During a concurrent interview and record review on 5/2/2024 at 1:35 p.m. with DD of Patient 4s EMR, DD stated Patient 4 did not have a plan of care. DD stated Patient 4 needed to have a plan of care. 5. A review of Patient 5s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/7/2024" with a hospice diagnosis of end stage heart failure (heart unable to pump adequately, shortness of breath, fatigue, and irregular heartbeat even while at rest). During a review on 4/30/2024 at 3:06 p.m. of Patient 5s EMR form titled ";End of Care Summary" dated 3/28/2024, indicated MD2 was listed under ";Physician". Lastly, the form indicated it was left blank and it was not signed by MD2. 6. A review of Patient 8s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 8s medical record form titled ";Initial Nursing Assessment Initiated 4/25/2024" form indicated it was not complete. The following areas were not assessed vital signs to include blood pressure, temperature, pulse, respiratory rate; current weight; functional limitation, activities permitted, mental status, memory recall, skin, musculoskeletal, sensory, cardiovascular, gastrointestinal, pain assessment, respiratory, endocrine, nutrition/hydration, genitourinary, reproductive, additional assessment, activity of daily living, psychosocial assessment, spiritual assessment, skilled care/Services provided, coordination of care, equipment/supplies, plan of care, eligibility assessment, teaching, need for comprehensive assessment, attending physician, and summary/plan/support diagnosis. During a concurrent interview and record review on 4/30/2024 at 3:15 p.m. with the DD of Patient 8s EMR, DD stated Patient 8s start of care date was 4/25/2024. DD stated she was unable to locate an initial nursing assessment for Patient 8 that was supposed to be completed by 4/25/2024. DD stated Patient 8 did not have a documented plan of care. During a review of Patient 8s medical form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 4/26/2024, indicated there were no signatures in sections Physician, Registered Nurse (RN), Spiritual Counselor (SC), and Social Worker (MSW) were left blank. The form also indicated Medical Doctor 1 (MD1) and MD2s names were printed in section ";Physician Name, Signature, Date". 7. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). A record review of Patient 9s document titled, ";Certification of Terminal Illness", for certification period 3/27/2024 to 6/24/2024, indicated, ";I have reviewed and agree with the Plan of care that includes Initial Orders and Plan of Care, Medication Profile and Plan of Care Problems (identified in assessments) and admission to hospice." Further review of the record indicated MD 2s name. The record was not signed because it did not indicate ";e-sign". During an interview on 5/3/2024, at 11:27 a.m. MD 2 stated he had not seen and examined Patient 9. 8. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A record review of Patient 10s ";Certification of Terminal Illness", for certification period 1/2/2024- 3/31/2024, indicated a narrative was written and the hospice doctors name was MD 3. The record was not signed. A record review of Patient 10s ";Certification of Terminal Illness", for certification period 4/1/2024 -6/29/2024, indicated a narrative was written and the hospice doctors name was MD 2. The section titled, ";Hospice Physician Signature" and ";Date" were blank. 9. During a review of Patient 11s medical record form titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). The form also indicated MD2 was listed as the hospice and attending physician. During a review of Patient 11s medical record form titled ";Certification of Terminal Illness" dated 2/27/2024 to 4/26/2024, indicated MD1 was listed as her hospice and attending physician. The form indicated it was not signed by MD1. During a review of Patient 11s medical record form titled ";Certification of Terminal Illness" dated 4/27/2024, indicated MD1 was listed as her hospice physician. The form also indicated it was not signed by MD1. During a review of Patient 11s medical record form titled ";Initial Orders and Plan of Care" dated 2/27/2024, indicated MD2 was listed as the hospice and attending physician. The form also indicated it was not signed by MD2. During a review of Patient 11s medical record form titled ";Physician Order Details" dated 4/18/2024, indicated ";Recertify patient... under routine care for the 6th benefit period starting 4/27/2024 to 6/25/2024...". The form also indicated MD1 was listed as the ";Physician". Lastly, the form was not signed by MD1. During a concurrent interview and record review on 4/30/2024 at 3:53 p.m. with the DD of Patient 11s EMR, DD stated Patient 11s CTI was not signed. During a telephone interview on 5/2/2024 at 11:16 a.m. with MD1, MD1 stated he did not certify Patient 11 for hospice services. MD1 stated Patient 11 did not meet hospice criteria. During a telephone interview on 5/3/2024 at 11:23 a.m. with MD2, MD2 stated he did not treat Patient 11. 10. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). A review of Patient 12s ";Certification of Terminal Illness", for certification period 1/9/2024-4/7/2024, indicated a narrative was written and the hospice doctors name was MD 3. The record was not signed. A review of Patient 12s ";Certification of Terminal Illness", for certification period 4/8/2024 -7/6/2024, indicated a narrative was written and the hospice doctors name was MD 1. The section titled, ";Hospice Physician Signature" and ";Date" were blank. A record review of the HAs policy and procedure titled, ";Contents of Clinical Record", dated April 2020, indicated, ";Procedure...2. Documentation will include...M. Signed and dated clinical notes...3. Each entry will be dated and signed, including title and credentials, by the person providing the care/service."

Based on interview and record review the Hospice Agency (HA) failed to ensure the Condition of Participation for Personnel Qualification was met as evidence by: --- 1. The HA failed to provide evidence their licensed professionals were qualified and licensed to provide patient care for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 4, Patient 9, Patient 10, Patient 11, and Patient 12). (Refer to L784). 2. The HA failed to provide evidence Certified Home Health Aide 1 (CHHA1) had the training and qualifications to provide patient care for one of fourteen sample patients (Patient 4). (Refer to L786). 3. The HA failed to provide evidence criminal background checks were done for their staff before providing care and services for fourteen of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L795). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations to ensure certified hospice patients were being cared for by qualified personnel.

Based on interview and record review the Hospice Agency (HA) failed to provide evidence their licensed professionals were qualified and licensed to provide patient care for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 4, Patient 9, Patient 10, Patient 11, and Patient 12). This failure had the potential to result in patients being taken care of unqualified and unlicensed staff which potentially can cause harm and injury to patients. --- During an interview on 4/29/2024 at 11:15 a.m., with the Administrator (ADM), the ADM stated Entity 1 (EN1) seized all the HAs documents including employee files. ADM stated new employee files were in a van (type of vehicle). During an interview on 5/2/2024 at 11:35 a.m., with ADM, ADM stated he did not have any employee records because EN1 took them all in March 2024. ADM stated there was no way to verify staffs qualifications. During an interview on 5/2/2024 at 12:05 p.m., with ADM, ADM stated he had no employee files. During a concurrent interview and record review on 5/4/2024 at 2 p.m., with the ADM of employee files, ADM provided the DDs employee file. ADM did not provide other employee files. 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). A record review of Patient 1s document titled, ";Initial Orders and Plan of Care", dated 1/5/2024, did not indicate a plan of care was formulated. There was no indication of the skilled nursing services (SN) and medical social worker (MSW) frequency being provided. During an interview on 4/30/2024, at 1:09 p.m., DD stated the IDG group documented the meeting in the electronic medical record (EMR) right away. Each discipline had their own computer access, and each discipline entered their own note in the EMR. DD stated the IDG group, included the registered nurse (RN) and medical social worker (MSW) who met every two weeks. A record review of Patient 1s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/5/2024, did not have any entries/narratives documented for the SN and MSW. Further review of the record indicated names of the SN, MSW 1, and MSW 2. However, there was no signatures in the document. A record review of Patient 1s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/19/2024, did not have any entries/narratives documented for the SN and MSW. Further review of the record indicated names of the SN, MSW 1, and MSW 2. However, there was no signatures in the document. 2. A review of Patient 2s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 2s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 1/5/2024, indicated the form also indicated it was not singed by SN and MSW services. During a review of Patient 2s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated ";SW Report" was left blank. The form also indicated it was not singed by SN and MSW staff. During a review of Patient 2s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated ";SW Report" was left blank. The form also indicated it was not singed by SN and MSW staff. During a review of Patient 2s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated ";SW Report" was left blank. The form also indicated it was not singed by SN and MSW staff. 3. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated the form was not singed by SN and MSW staff. During a review of Patient 4s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated it was not singed by SN and MSW staff. During a review of Patient 4s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated ";SW Report" section was left blank. The form also indicated it was not singed by SN and MSW staff. 4. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). During an interview and record review on 4/30/2024, at 10:45 a.m., Patient 9s second caregiver (CG 2) stated she wrote all the visits Patient 9 has received in a notebook. The notebook indicated Patient 9 received visits from the HA on 3/27/2024, 4/10/2024, 4/13/2024, and 4/30/2024. CG 2 stated she did not remember a social worker coming to the home or talking on the phone with them. A record review of Patient 9s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/5/2024. The record indicated, ";SW Report IDT 4/5/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family." A record review of Patient 9s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/19/2024, indicated, ";SW Report IDT 4/19/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family. Further review of the record indicated names of the SN, MSW 1, and MSW 3. However, there were no signatures on the document. 5. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A record review of Patient 10s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 1/2/2024, indicated, ";SW Report IDT 1/2/2024. MSW visits-Initial assessment within 5 days to provide psychosocial support to patient and family." A record review of Patient 10s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment" for the following dates: 1/26/2024, indicated patient declined MSW services. Further review of the record did not indicate the name and signature of the SN and MSW staff. 2/9/2024, indicated patient declined MSW services. Further review of the record did not indicate the name and signature of the SN and MSW staff. 2/23/2024, indicated patient declined MSW. Further review of the record did not indicate the name and signature of the SN and MSW staff. 3/8/2024, indicated patient declined MSW. Further review of the record did not indicate the name and signature of the SN and MSW staff. 3/22/2024, indicated patient declined MSW. Further review of the record did not indicate the name and signature of the SN and MSW staff. 6. A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). During a review of Patient 11s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/8/2024, indicated it was not singed by SN and MSW staff. During a review of Patient 11s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 3/22/2024, indicated it was not singed by SN and MSW staff. During a review of Patient 11s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/5/2024, indicated it was not singed by SN and MSW staff. During a review of Patient 11s medical record form titled ";IDT plan of Care & Review of Comprehensive Assessment" dated 4/19/2024, indicated was not singed by SN and MSW staff. 7. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease). A record review of Patient 12s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", for dates: 1/12/2024, indicated patient declined MSW services. Further review of the record did not indicate the name and signature of the SN and MSW staff. 1/26/2024, indicated patient declined MSW services. Further review of the record did not indicate the name and signature of the SN and MSW staff. 2/9/2024, indicated patient declined MSW services. Further review of the record did not indicate the name and signature of the SN and MSW staff. 2/23/2024, indicated patient declined MSW. Further review of the record did not indicate the name and signature of the SN and MSW staff. 3/22/2024, indicated patient declined MSW. Further review of the record did not indicate the name and signature of the SN and MSW staff. A review of the HAs undated document titled, ";Organizational Chart", indicated the name of MSW 1 and indicated, ";Medical Social Worker". A review of the HAs policy and procedure titled, ";Scope of Services", dated April 2020, indicated, ";Policy: Bright and White Hospice provides hospice services that are intended to meet the physical, psychosocial, practical, and spiritual needs of patients and families/caregivers...core hospice services provided by nurses, social workers, physicians, and bereavement counselors...are available 24 hours a day, seven (7) days a week...3. An interdisciplinary group of professionals and volunteers will develop with each patient and family/caregiver a plan of care, which include, as appropriate, the following services: A. Physician. B. Registered Nurse. C. Medical Social Worker...E. Spiritual Support...".

Based on interview and record review the Hospice Agency (HA) failed to provide evidence Certified Home Health Aide 1 (CHHA1) had the training and qualifications to provide patient care for one of fourteen sample patients (Patient 4). This failure had the potential to result in Patient 4 being taken care of by an unqualified CHHA which had the potential to cause harm and injury. --- During an interview on 4/29/2024 at 11:15 a.m., with the Administrator (ADM), the ADM stated Entity 1 (EN1) seized all the HAs documents including employee files. ADM stated new employee files were in a van. During an interview on 5/2/2024 at 11:35 a.m., with ADM, ADM stated he did not have any employee records because EN1 took them all in March 2024. ADM stated there was no way to verify staffs qualifications. During an interview on 5/2/2024 at 12:05 p.m., with ADM, ADM stated he had no employee files. During a review of Patient 4s medical record form titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). During a review of Patient 4s medical record form titled ";Physician Order Details" dated 3/1/2024, indicated ";SN (skilled nurse): 1 per week and 1-2 as needed visit/s...". The form also indicated ";CHHA – service offered but declined." During an interview on 5/1/2024 at 11:15 a.m., with Patient 4s Caretaker 1 (CT1), CT1 stated Patient 4 receives hospice CHHA services twice a week, on Tuesday and Thursday. During a concurrent interview and record review on 5/2/2024 at 11:50 a.m., with the Director of Nurses Designee (DD) of Patient 4s Electronic Medical Record (EMR), DD stated Patient 4 did not have a documented CHHA care plan or CHHA visit notes since his start of care, 3/1/2024, in his EMR. DD stated Patient 4 did not have a physician order for CHHA services, but the HA received CHHA1s routing sheets that stated she saw Patient 4 twice a week. DD stated CHHA1 did not have a plan of care for Patient 4.

Based on interview and record review the Hospice Agency (HA) failed to provide evidence criminal background checks were done for all staffs before providing direct care and services for fourteen of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in patients being taken care of by unqualified personnel that could jeopardize the health and safety of the patients certified to receive the home health benefits. --- 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). 2. A review of Patient 2s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). 3. A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). 4. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). 5. A review of Patient 5s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/7/2024" with a hospice diagnosis of end stage heart failure (heart unable to pump adequately, shortness of breath, fatigue, and irregular heartbeat even while at rest). 6. A review of Patient 6s medical record form titled ";Initial Orders and Plan of Care", indicated a start of care date on 1/22/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). 7. A review of Patient 7s medical record form, indicated ";Date Initial Nursing Assessment Initiated 1/9/2024" with a hospice diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). 8. A review of Patient 8s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). 9. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). 10. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). 11. A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). 12. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory). 13. A review of Patient 13s record titled ";Bright and White Hospice", indicated a start of care date on 1/2/2024, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). 14. A review of Patient 14s record titled, ";Bright and White Hospice", indicated a start of care date on 1/2/2024, with a primary diagnosis of hypertensive heart disease without heart failure. During an interview on 4/29/2024 at 11:15 a.m., with the Administrator (ADM), the ADM stated Entity 1 (EN1) seized all the HAs documents including employee files. ADM stated new employee files were in a van. During an interview on 5/2/2024 at 11:35 a.m., with ADM, ADM stated he did not have any employee records because EN1 took them all in March 2024. ADM stated there was no way to verify staffs qualifications. During an interview on 5/2/2024 at 12:05 p.m., with ADM, ADM stated he has no employee files. During a concurrent interview and record review on 5/4/2024 at 2 p.m., with the ADM of employee files, ADM provided the DDs employee file. ADM did not provide other employee files. A review of the HAs policy and procedure titled, ";Patient Bill of Rights/Responsibilities", dated April 2020, indicated, ";Procedure: 1. The Patient Bill of Rights/Responsibilities statement defines the right of the patient to...I. Be free from mistreatment, neglect or verbal, mental, corporal punishment, sexual and physical abuse, including injuries of an unknown source, and misappropriation of patient property."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to operate services in accordance with the Federal and State licensure laws. This failure resulted in the HA providing services for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12) from an unknown location. --- During an observation on 4/29/2024, at 9:15 a.m., the business location indicated the agency was operating inside a room in a dental clinic. There was no signage outside the clinic identifying the hospice agency. Inside the dental clinic, there was a paper posted in the receptionist area indicating the hospice agency was in suite ";C". Suite ";C" was in the back corner of the dental clinic. The room did not have any computers, phones, printers, file cabinets, and patient records. During an interview on 4/29/2024, at 9:42 a.m., the Administrator (ADM) stated the paper charts of all the patients being cared for by the agency were being stored at another business location and Entity 1 (EN 1) took the paper documents in March 2024. The ADM stated the office equipment was being stored in a van because the HA was moving to a new location starting May 1, 2024. The ADM stated he had notified the State Department of the new location last week and would ask the consultant for a copy of the application to provide to the survey team. During an interview on 4/29/2024 at 9:43 a.m. with the ADM, the ADM stated patients medical records were stored on their Electronic Medical Record (EMR) system. During an interview on 4/29/2024, at 10:15 a.m., the ADM stated the current location, as listed in the facility profile, was the location of the business and would go and get all equipment, records and return to the current location. During an observation on 4/29/2024, at 11:12 a.m., the ADM returned to the current location with a white computer screen, white keyboard, white mouse, and a black printer. During an interview on 4/29/2024 at 11:15 a.m. with the ADM, the ADM stated the HAs physical medical records were confiscated by Entity 1 (EN1) in March 2024, due to being stored at a different location, other than the current one. On 4/29/2024 at 11:17 a.m., the State Department was contacted. The HA did not submit an application for a change of location. During an observation of the new location on 5/2/2024, at 9:30 a.m., the ADM provided a tour of the office. The office consisted of two room. The rooms were completely empty. There was no desk, no chairs, no printers, no computers, no phones, no furniture, and no file cabinets. The ADM stated he would be moving into the new location ";this weekend". 1. A review of Patient 1s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (coronary artery disease, plaque buildup in the blood affecting the blood flow, without chest pain). 2. A review of Patient 2s record titled ";Patient Face Sheet", indicated a start of care date on 1/5/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). 3. A review of Patient 3s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of chronic systolic congestive heart failure (heart is not pumping blood effectively). 4. During a review of Patient 4s record titled ";Patient Face Sheet", indicated a start of care date on 3/1/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). 5. A review of Patient 8s record titled ";Patient Face Sheet", indicated a start of care date on 4/25/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) without heart failure (heart not pumping blood properly). 6. A review of Patient 9s record titled ";Patient Face Sheet", indicated a start of care date on 3/27/2024 with a primary diagnosis of heart failure (heart is not pumping blood effectively). 7. A review of Patient 10s record titled ";Patient Face Sheet", indicated a start of care date on 1/2/2024 with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). 8. A review of Patient 11s record titled ";Patient Face Sheet", indicated a start of care date on 2/27/2024 with a primary diagnosis of hypertensive heart disease (long term high blood pressure causing changes to the left side of the heart) with heart failure (heart not pumping blood properly). 9. A review of Patient 12s record titled ";Patient Face Sheet", indicated a start of care date on 1/9/2024 with a primary diagnosis of Alzheimers disease (a brain disease that affects memory).