Every finding on record at Cali Care Hospice

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Organization and Administration of Services was met as follows: 1. The hospice agency failed to ensure the Administrator was knowledgeable regarding hospice regulations and the agency was operational. (Refer to L651). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Organization and Administration of Services to protect and promote the rights of the patient in the hospice agency. --- Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Organization and Administration of Services was met as follows: 1. The hospice agency failed to ensure that the Administrator was knowledgeable regarding hospice regulations and that the agency was operational. (Refer to L651). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Organization and Administration of Services to protect and promote the rights, of the patient in the hospice agency.

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

Based on interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: 1. The hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment and review, and verified the patient clinical information, necessary for initial certifications of two of 6 sample patients, (Patients 1 and Patient 3) to support diagnosis of the patients terminal illnesses and to qualify for hospice (healthcare that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care (Refer to L 667). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services. --- .

Based on interview, and record review, the hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial certifications of two of six sample patients, (Patients 1, and Patient 3) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. These deficient practices resulted in the hospice medical director and/or the hospice attending physicians certifying the patients for hospice care, without documentation of clinical evidence to support the terminal illness diagnoses and could result in a lack of and inappropriate care provided to the patients. --- a. A review of Patient 1s Patient Information Sheet indicated a start of care (SOC) date of 8/22/22 and an end of care (EOC) date of 11/4/22. Patient 1s had a primary diagnosis of diastolic congestive heart failure (condition where the heart cannot pump or fill adequately. A review of Patient 1s Physician's Certification for Hospice Benefit," (CTI) for the first 90- day period from 8/28/22 to 11/25/22 indicated that Patient 1 had secondary diagnoses which included hypertensive heart disease (high blood pressure), shortness of breath and weakness. Patient 1 did not have a physician face to face summary, or a certifying physician summary documented. Patient 1s CTI was not signed by the medical director (MD 2). A review of Patient 3s Patient Information Sheet indicated a SOC date of 9/22/23 and EOC date of 10/26/22. Patient 3 had a primary diagnosis of chronic ischemic heart disease. A review of Patient 3s CTI for the first 90- day period from 9/22/22 to 12/20/22, indicated that Patient 3 had secondary diagnoses of chronic kidney disease (when kidney no long function properly to filter waste from the blood), hypertensive heart disease and angina. Patient 3 did not have a physician face to face summary, or a certifying physician summary documented. Patient 3s CTI was not signed by Physician 2. On 5/4/23, Physician 2s employee file was requested, but could not be found. During an interview on 5/4/23, at 11:30am, Registered Nurse (RN 1) stated that she did not know why CTIs were not signed by the medical director. RN 1 stated that the CTIs should be signed by the medical director because they are the ones that certify that the patients qualify for hospice. During an interview on 5/8/23 at 10:34 am, Physician 2 stated that she never filled out a job application for the hospice agency (HA). Physician 2 stated that she was not seeing any patients from the HA, she did not sign any CTIs and did not certify any patients for hospice. A review of the HA's policy titled " Physician Services-Attending Physician Role ", (undated), indicated that the attending physician or designee will approve the referral of the patient and family/caregiver to the hospice program, and provide written initial certification and narrative of the terminal illness.

Based on interview and record review the hospice agency (HA) failed to meet the Condition of Participation for Clinical Records as follows; 1.The HA failed to ensure documentation and the patient's medical information were accurate, complete, and authentic signature of the responsible discipline, for four of six sampled patients (Patient 2, 4, 5, 6). For Patient 2, the Physician's Certification for Hospice Benefit was signed by an unknown staff member. For Patient 4, 5, and 6, the patient certification for hospice benefit was left blank and did not indicate the physician's signature. (Refer to L679). 2. The HA failed to maintain the paper or hard copy of the patient's medical records as a backup, in case the electronic medical records were not accessible for six of six sampled discharged patients (Patient 1, 2, 3, 4, 5 and 6). (Refer to L681). 3. The HA failed to maintain a complete discharge summaries for Patients 1, 4 and 5 (Refer to L684). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated Federal compliance to ensure safety and the highest quality care and services were provided to the patients certified to receive hospice care and benefits. --- .

Based on record review and interview, the Hospice Agency (HA) failed to ensure documentation and the patient's medical information were accurate, complete, and authentic signature of the responsible discipline, for four of six sampled patients (Patient 2, 4, 5, 6). For Patient 2, the Physician's Certification for Hospice Benefit was signed by an unknown staff member. For Patient 4, 5, and 6, the patient certification for hospice benefit was left blank and did not indicate the physician's signature. This deficient practice resulted in failure to document accurately and ensure authenticity of the patients' clinical records. --- b. A review of Patient 4s Patient Information Sheet, indicated a start of care (SOC) date of 9/18/2022, with a primary diagnosis of hypertensive heart disease with heart failure (a chronic condition when the heart does not pump as well as it should). A review of Patient 4"Physician's Certification for Hospice Benefit," (CTI #1) for the first 90- day period from 9/18/2022 to 12/16/2022, indicated a terminal diagnosis of hypertensive heart disease with heart failure. The CTI #1 was signed by the Medical Director (MD 2) and did not indicate any communication between MD 2 and Patient 4s Primary Care Physician (PCP 1) to validate that Patient 4 had a life expectancy of six months or less, if the terminal illness ran its normal course. A review of Patient 4's Comprehensive Nursing Assessment dated 9/18/22 from 8:30 a.m. to 10:30 a.m. indicated Vital signs & measurements were blank. mobility, Nature & conditions of Terminal Illness/LCD Eligibility, Body system head to toe was blank. Under Narrative & Disease Trajectory, someone documented, "Comprehensive head-to toe assessment and medication reconciliation completed. The patient's current condition, medication and treatment have been reviewed with the MD via telephone." However, the comprehensive assessment was blank and there was no signature of the discipline completing the assessment. Review of patient 4's plan of care (POC) was blank except for the typed named of MD2. c. A review of Patient 5's face sheet indicated a SOC of 9/22/22 for the certification period of 9/22/22 to 12/20/22, with a terminal diagnosis of Carcinoma in situ of prostate. There was no telephone number documented on the face sheet for Patient 5 or their emergency contact. A review of Patient 5s "Physician's Certification for Hospice Benefit," (CTI) #1 for the first 90- day period from 8/29/2022 to 11/26/2022, indicated a terminal diagnosis of hypertensive heart disease with heart failure. The CTI Certifying Physician Summary indicated that Patient was deemed to be hospice appropriate with a terminal diagnosis of 6 months or less. A review of Patient 5's Comprehensive Nursing Assessment dated 9/26/22 from 5:15 p.m. to 5:45 p.m. indicated Vital signs & measurements were blank. mobility, Nature & conditions of Terminal Illness/LCD Eligibility, Body system head to toe was blank. Under Narrative & Disease Trajectory, someone documented, "Comprehensive head-to toe assessment and medication reconciliation completed, the patient's current condition, medication, and treatment have been reviewed with MD via telephone." however, the comprehensive assessment was blank and there was no signature of the discipline completing the assessment. Review of patient 5's Plan of care (POC) was blank except for the typed named of MD2. Review of patient 5's Plan of care (POC) was blank except for the typed named of MD2. Review of the LCD Eligibility form was blank. d. A review of Patient 6s Patient Information Sheet, indicated a start of care (SOC) date of 8/29/2022, with a primary diagnosis of Chronic Obstructive Pulmonary disease( a group of lung diseases that blocks airflow making it difficult to breathe.) A review of Patient 6s "Physician's Certification for Hospice Benefit," (CTI) #1 for the first 90- day period from 8/29/2022 to 11/26/2022, indicated a terminal diagnosis of chronic obstructive pulmonary disease. The CTI Certifying Physician Summary indicated that Patient was deemed to be hospice appropriate with a terminal diagnosis of 6 months or less. A review of Patient 6's Comprehensive Nursing Assessment dated 8/29/22 from 5:45 p.m. to 6:15 p.m. indicated Vital signs & measurements were blank. mobility, Nature & conditions of Terminal Illness/LCD Eligibility, Body system head to toe was blank. Under Narrative & Disease Trajectory, someone documented, "Comprehensive head-to toe assessment and medication reconciliation completed, the patients current condition, medication, and treatment have been reviewed with MD via telephone." The comprehensive assessment was electronically signed on 10/12/22 by Workman 1 as the Administrator, to close note on behalf of staff assigned. Review of patient 6's Plan of care (POC) was blank except for the typed named of MD2. Review of patient 6's Plan of care (POC) was blank except for the typed named of MD2. Review of the LCD Eligibility form was blank. During a telephone interview with MD2 on 5/4/23, at 12:52 p.m., she stated much of this was done without her knowledge and she never was asked or filled out an application for this hospice. During an interview with the DPCS in the hospice agency's conference room on 5/4/23, at 1p,m, regarding the comprehensive assessments reviewed, she stated they should have been completed and the hospice agency should have contact numbers to reach the patients. The DPCS stated she does not have access to hospice MD due to them not having patients at this time. During an interview with the CEO in the office of the hospice agency she stated that MD2 was not compliant with reviewing the patients. The CEO was unable to provide a contract or application/employee file for MD2. a. A review of Patient 2s Patient Information Sheet (face sheet) indicated a SOC date of 9/16/22 and EOC date of 10/29/22. Patient 2 had a primary diagnosis of chronic ischemic heart disease (heart weakening caused by reduced blood flow to the heart). A review of Patient 2s Certification for Hospice Benefit (CTI) for the first 90- day period from 9/16/22 to 12/14/22, indicated that Patient 2 had secondary diagnoses of hypertensive heart disease, angina (chest pain) and atherosclerosis (buildup of fats, cholesterol, in and on the artery wall causing obstruction of blood flow). Patient 2s CTI was electronically signed by Medical director 2 (MD 2). On 5/4/23, MD 2s employee file was requested, but could not be found. During an interview on 5/8/23 at 10:34 am, MD 2 stated that she never filled out a job application for the HA. MD 2 stated that she was not seeing any patients from the HA, she did not sign any CTIs and did not certify any patients for hospice. A review of the HA's policy titled " Entries into the Clinical Record", (undated), indicated that hospice personnel providing direct patient care and supervisory functions have the authority to make entries into the clinical record...Personnel authorized to use a computer to authenticate documentation will sign a computer confidentiality statement, verifying that no one else will be allowed to use their computer password. Each staff member will be responsible for the security of his/her computer password.

Based on interview and record review, the hospice agency (HA) failed to retain the patient's paper medical record for six of six sampled residents for six years after discharge in accordance with its policy and procedure (Patient 1, 2, 3, 4, 5 and 6). This deficient practice resulted in the failure to safeguard and retain the patients clinical records. --- a. A review of Patient 1s Patient Information Sheet indicated a start of care (SOC) date of 8/22/22 and an end of care (EOC) date of 11/4/22. Patient 1 had a primary diagnosis of diastolic congestive heart failure (condition where the heart cannot pump or fill adequately. A review of Patient 1s discharge summary indicated a reason for discharge was hospitalization. The nurses narrative note was empty. b. A review of Patient 2s Patient Information Sheet indicated a SOC date of 9/16/22 and EOC date of 10/29/22. Patient 2 had a primary diagnosis of chronic ischemic heart disease (heart weakening caused by reduced blood flow to the heart). A review of Patient 2s discharge summary indicated that they were discharged due to patient and family declining further services. c. A review of Patient 3s Patient Information Sheet indicated a SOC date of 9/22/23 and EOC date of 10/26/22. Patient 3 had a primary diagnosis of chronic ischemic heart disease. A review of Patient 3s discharge summary indicated that they were discharged due to declining further services. d. A review of Patient 4s Patient Information Sheet indicated a SOC date of 9/18/22 and EOC date of 10/12/22. Patient 4 had a primary diagnosis of hypertensive heart disease with heart failure (when the heart cannot pump properly, caused by high blood pressure. A review of Patient 4s discharge summary indicated that they were discharged due to change in payor. e. A review of Patient 5s Patient Information Sheet indicated a SOC date of 9/22/22 and an EOC date of 10/30/22. Patient 5s primary diagnosis was carcinoma in situ of prostate (prostate cancer). A review of Patient 5s discharge summary indicated that they were discharged due to declining further services. f. A review of Patient 6s Patient Information Sheet indicated a SOC date of 8/29/22 and EOC date of 10/29/22. Patient 6 had a primary diagnosis of chronic obstructive pulmonary disease. A review of Patient 6s discharge summary indicated that they were discharged due to declining further services. On 5/4/23, at 12:20 p.m., Registered Nurse 1 (RN 1) was asked to find the paper charts for Patients 1, 2, 3, 4, 5, and 6, but she was unable to find any charts in the hospice agencies (HA) office. On 5/4/23, at 12:30 p.m., the agency's Owner stated, the patient's medical record were in other agencys office and sent licensed vocational nurse 1 (LVN 1) to the other agency to bring the patient's medical record. On 5/4/23 at 1:54 p.m., LVN 1 called and stated that he was not able to find any of the HAs patients paper medical records On 5/4/23, at 2pm, the Owner stated that she did not know where the hard copy of the patient's medical records. A review of the HA's undated policy titled "Record Retention", indicated clinical records will be retained for six (6) years. When a patient is discharged/expires, paper Records will be stored on the premises for two (2) years. After 2 years, the records will be properly labeled, boxed and stored off site in a secure storage facility.

Based on interview and record review, the hospice agency (HA), failed to complete discharge summary for three of six sampled patients (Patients 1, 4 and 5). This deficient practice resulted in the status of the patients' health condition at discharge was unknown. --- a. A review of Patient 1s Patient Information Sheet indicated a start of care (SOC) date of 8/22/22 and an end of care (EOC) date of 11/4/22. Patient 1 had a primary diagnosis of diastolic congestive heart failure (condition where the heart cannot pump or fill adequately). A review of Patient 1s discharge summary indicated an EOC date of 11/4/22, reason for discharge was hospitalization. The nurses narrative note was empty. b. A review of Patient 4s Patient Information Sheet indicated a SOC date of 9/18/22 and EOC date of 10/12/22. Patient 4 had a primary diagnosis of hypertensive heart disease with heart failure (when the heart cannot pump properly, caused by high blood pressure. A review of Patient 4s discharge summary indicated they were discharged due to change in payor. The nurses narrative note was empty. And the discharge summary was not signed by the documenting nurse. c. A review of Patient 5s Patient Information Sheet indicated a SOC date of 9/22/22 and an EOC date of 10/30/22. Patient 5s primary diagnosis was carcinoma in situ of prostate (prostate cancer). A review of Patient 5s discharge summary indicated that they were discharged due to declining further services. There was no other information in the nurse narrative note, and the discharge summary was not signed by the documenting nurse. During an interview on 5/4/23, at 12:13 p.m., Registered Nurse (RN) 1 stated that all patients should have a discharge summary, "so you know why they are being discharged" A review of the HAs undated policy titled ";Discharge From Hospice Program", indicated the hospice interdisciplinary group will develop a discharge plan that will include any necessary family counseling, patient education or other services needed prior to discharge. When a patient is discharged, relevant information will include: A. Reason for discharge B. Physical and psychosocial status at time of transfer or discharge, including specific medical, psychosocial, or other problems requiring interventions or follow-up. C. Summary of the care provided and progress toward achieving goals, including both positive and adverse patient responses to treatment or services. D. The date of discharge, which is the date of the last visit made.