Every finding on record at Care Unlimited Hospice Services, Inc.

d. A review of Patient 5's clinical record indicated, Patient 5 was 46 years female who started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) visit was once a week and as needed. The Medical Social Worker (MSW) visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. During a joint home visit with RN 1 on 9/7/2022, at 10:20 a.m., Patient 5 was observed walking using a cane from her car (which was parked in front of the house) to her house (back unit of the house). During an interview with RN 1 at the same time, she stated Patient 5 could drive. During an interview with Patient 5 on 9/7/2022, at 10:30 a.m., it was observed Patient 5 was alert, oriented, and was able to communicate well. Patient 5 stated she lives alone at her unit and she could drive her car to the doctor's office, grocery store, and she could go out for eating. She stated she could cook and shower. She stated she had declined the HA service because she could shower herself. When asked whether she had a pulmonary disease, she stated she had "Asthma" not pulmonary disease, and she did not think she would die within 6 months. A review of Patient 5's "Comprehensive Nursing Assessment" dated 12/28/2021 indicated Patient 5 was alert and oriented, had functional limitation of endurance, was ambulatory using a cane, and had steady gait. Patient 5 had mild dyspnea with mild exertion, and requires oxygen at 2 liters per minute as needed. Patient 5 was observed using chest accessory muscle after activity or walking, and the oxygen saturation at room air was 85 percent. The patient took two puffs of her Albuterol HFA 90 mcg oral inhalation, and after few minutes of rest, the patient's oxygen saturation had improved to 90 percent. Patient 5 had dull ache pain on both lower legs at a level of 4/10 on a pain scale. Diclofenac Sodium 1 % topical 2-4 times per day for pain management, and the pain was managed well ( reassessed pain prior to end the visit and the pain level was 2/10). A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Pulmonary Disease," dated 12/28/2021, indicated the section 1 and 2 should be met. It indicated Patient 5 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, is less than 30 percent of predicted * Increased visits to Emergency Room A review of Patient 5's record indicated there was no documented evidence Patient 5 was poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity, had Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. A review of Patient 5's record indicated there was no documentation supporting the LCD assessment. A review of Patient 5's form titled, "Physician's Certification for Hospice Benefit" (the document that showed a physician certified a patient's eligibility for hospice benefit), from 12/28/2021 to 3/27/2022, indicated, Patient 5's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 5's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". e. A review of Patient 6's clinical record indicated, Patient 6 was 64 years old male who started hospice care on 7/14/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit once per 2 week plus one visit and LVN visit once per week and one visit as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 6's "Comprehensive Nursing Assessment" dated 7/14/2021 indicated Patient 6 was alert and oriented, used a cane for ambulation, and bowel and urinary status was continent. Patient 6 had mild dyspnea with mild exertion, and oxygen saturation was 96 percent. The need of Hospice aide, volunteer and community support was check marked as "None". A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 7/14/2021, indicated the section 1 and 2 should be met. It indicated Patient 6 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Increased visits to Emergency Room *Oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor A review of Patient 6's record indicated there was no documented evidence Patient 6 was poorly responsive or unresponsive to bronchodilators, or had Increased visits to Emergency Room, and the oxygen saturation rate was less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 6's record indicated there was no documentation supporting the LCD assessment. A review of Patient 6's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 6's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 6's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 6 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". f. A review of Patient 7's clinical record indicated, the patient was 60 years old male who started hospice care on 2/8/22, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit two times per 2 weeks 2 week plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's "Comprehensive Nursing Assessment" dated 2/28/2022 indicated Patient 7 was alert and oriented, used a cane for ambulation. Patient 7 had mild dyspnea with mild exertion, and oxygen saturation was 97 percent. It indicated "No" for the question of whether the patient was uncomfortable because of pain. The need of Hospice aide, was check marked as "None". The need for the Volunteer or community support was blank. The nurse's narrative indicated Patient 7 was observed with on and off shortness of breath and was on Albuterol 90 mcg/Actuation inhalation Aerosol 90 mcg 1-2 puffs inhaler three times a day as needed for shortness of breath/wheezing. Patient 7 had generalized body pain and was on Norco 10 mg-325 mg one tablet by mouth every 6 hours as needed for pain. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 2/28/2022, indicated the section 1 and 2 should be met. It indicated Patient 7 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure *Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 millimeter Mercury (mmHg). A review of Patient 7's record indicated there was no documented evidence Patient 7 was poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, Hypoxemia (an abnormally low concentration of oxygen in the blood) at rest on room air, as evidenced by pO2 (partial pressure of oxygen - a measure of the tension or pressure of oxygen dissolved in the blood - If a pO2 level is lower than 80 mmHg, it means that a person is not getting enough oxygen) less than or equal to 55 millimeter mercury (mmHg). A review of Patient 7's record indicated there was no documentation supporting the LCD assessment. A review of Patient 7's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 7's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 7 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 7's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". g. A review of Patient 8's clinical record indicated, the patient was 44 years old male who started hospice care on 1/21/22, with a terminal diagnosis of COPD. It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated the RN visits for initial assessment, supervisory visit, and ongoing comprehensive assessment, reassessment, recertification and as needed. The Skilled Nurse (SN) visit once a week and onece per week as needed. The MSW was to visit within 5 days from the SOC, Certification and as needed. The HA service and the volunteer services were offered and declined. A review of Patient 8's "Comprehensive Nursing Assessment" dated 1/21/2022 indicated Patient 8 was alert and oriented, needed stand by assist for ambulation. Patient 8 had mild dyspnea with mild exertion, and oxygen saturation was 92 percent. Patient 8 was continent in bowel and bladder. The need of Hospice aide, and the need of community support were check marked as "None". The need for the Volunteer was check marked for errands. The nurse's narrative indicated Patient 8 was 43 years old male with last hospitalization on 9/18/2021 to 9/21/2021 for evaluation and treatment of left lower extremity torn ligament. According to the patient, his condition had progressively deteriorated in the past few months, evidence of dyspnea with activity and even at rest. Upon assessment, the patient was sitting in a chair and had a pain level to be 8/10. The patient was placed with medication of Norco 10/325 mg one tablet orally every 6 hours as needed for moderate to severe pain and Tylenol 500 mg every 6 hours for breakthrough pain. At the end of the visit and assessment, the patient was noted relaxed without any discomfort, no shortness of breath, and the pain level was 0/10. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 1/21/2022, indicated the section 1 and 2 should be met. It indicated Patient 8 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure * Oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documented evidence Patient 8 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, oxygen saturation less than or equal to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documentation supporting the LCD assessment. A review of Patient 8's form titled, "Physician's Certification for Hospice Benefit" from 1/21/2022 to 4/20/2022, indicated, Patient 8's terminal diagnoses was COPD. It was indicated in the physician's narrative that Patient 8 no longer wants to continue aggressive treatment and stated he wanted comfort measures only. It was indicated in the section of "Certifying Physician Summary" that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 8's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". During an interview with the Director of Patient Care Services (DPCS) on 9/8/2022, at 4:15 p.m., she stated she was not able to find the documented evidence Patient 5, 6, 7, 8 were poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity, Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patients' primary physicians that Patient 5, 6, 7, 8, had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of the agency's comprehensive assessment revised in April 2017 indicated the agency must assure the data elements allow for measurement of outcomes, and the Clinical Supervisor/Nursing Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). A review of the agency's undated Policy and Procedure titled "Certification of Terminal Illness" indicated the clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification.

Based on observation, interview and record review, the hospice agency (HA) failed to maintain an accurate, and current medication profile for one of 11 sampled patients (Patient 5). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. Findings: A review of Patient 5's clinical record, indicated a start of care (SOC) date of 4/27/22, with a diagnosis that included chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 5's Plan of Care (POC), for the certification period from 4/27/22 to 7/25/22, it included an order for skilled nurse (SN) to visit 1 per week and as needed for nine weeks for skilled assessment and interventions. On 7/29/22, at 11:00 a.m., a home visit was conducted at Patient 5's residence with the Registered Nurse (RN 1). Patient 5 was observed sitting on a recliner, and RN 1 proceeded to render care. During a review of Patient 5's medications, on 7/29/22 at 11:20 a.m., Colace 100 milligram (mg) 1 capsule by mouth daily was not found. However, the hospice's medication profile indicated the patient was taking the medication. On 7/29/22, at 11:30 a.m., during an interview with Patient 5's daughter (FM 1), she stated she disposed the medication several months back because Patient 5 was not taking it. On 8/01/22, at 12:30 p.m., during an interview with the Director of Patient Care Services (DPCS), she stated patient's medication should be check and reconciled on every skilled nurse visit and to update the medication profile in the patient clinical records. A review of the HA's policy and procedure titled, "Medication Profile", dated November 2021, indicated patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications.

Based on interview and record review the facility failed to provide the bereavement services (emotional, psychosocial, and spiritual support services provided to the family before and after the death of the patient to assist the family in coping with issues related to grief, loss, and adjustment) for up to after one year after the patient's death to surviving family/caregiver member for two of 13 sampled patients, (Patients 1 and 9), This deficient practice has the potential to not provide social, spiritual and cultural supports to the patients/family related to the patient's death. Findings: a. A review of Patient 1's clinical record indicated a start of care (SOC) date of 7/20/2021, with a primary diagnosis of cerebrovascular disease (a group of conditions, diseases, and disorders that affect the blood vessels and blood supply to the brain). A review of Patient 1's "Certification of Terminal Illness" (CTI, terminal illness certifying a prognosis of having 6 months of life or less) indicated Patient 1 had a life expectancy of six months or less if the terminal illness ran its normal course. A review of Patient 1's "Discharge Summary," dated 8/14/2021, indicated Patient 4 passed away of natural causes on 8/14/2021. A review of Patient 1's clinical record indicated there was no documented evidence bereavement services (emotional, psychosocial, and spiritual support services provided to the family before and after the death of the patient to assist the family in coping with issues related to grief, loss, and adjustment) was conducted after and up to one year. During an interview with the Director of Patient Care Services (DPCS) on 9/12/2022, at 3 p.m., DPCS was not able to provide the documented evidence bereavement services was provided after death and up to one year. b. A review of Patient 9's record indicated Start of Care (SOC) was 12/22/2020 and the patient had passed away on 6/7/2021. A review of the Discharge Summary" dated 6/7/2021 indicated Patient 9, who was residing at the housing facility was found on the floor by the facility's administrator. The administrator called 911 and the patient was pronounced dead, and the patient's family was made aware by the Administrator of the housing facility. A review of Patient 9's clinical record indicated there was no documented evidence bereavement services was conducted after and up to one year. During an interview with the Director of Patient Care Services on 9/12/2022, at 3 p.m., she was not able to provide the documented evidence bereavement services was provided after death and up to one year. A review of the facility's policy titled "Bereavement Assessment" revised in April 2017 indicated the facility will provide bereavement services for up to one year after the patient's death to surviving family/caregiver members.