Every finding on record at Comfort Destiny Hospice, Inc

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation regarding Patient Rights were met as followed: --- . 1. The HA failed to provide one of six sampled patients (Patient 4) information on their rights as a hospice patient in a language that would be understood and preferred by the patient. (Refer to L502). 2. The HA failed to provide written information regarding advance directive policies and description for one of six sampled patients (Patient 4). (Refer to L503). 3. The HA failed to inform four of six sampled patients (Patient 1, Patient 2, Patient 4, and Patient 6) about the services they provide and the limitations on those services. (Refer to L519). The cumulative effect of these systemic practices resulted in patients not knowing their hospice services with their limitations and their rights as hospice patients.

Based on interview, observation, and record review, the Hospice Agency (HA) failed to provide two of six sampled patients (Patient 4 and Patient 5) information on their rights as a hospice patient in a language that would be understood and preferred by the patient. This failure resulted in the patient not fully understanding or knowing their rights as a hospice patient. --- , A record review of Patient 4s (P4) ";Personal Information", indicated P4 had a Start of Care (SOC) date of 2/9/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. During a home visit on 6/28/23, at 10:20 a.m. Registered Nurse 1 (RN 1) was observed providing care to P4. During the home visit on 6/28/23, at 11:38 a.m. a lavender folder was observed in P4s home. The folder had the name of the agency. Inside the folder was a copy of P4s plan of care. No other documents in the folder were observed. During an interview, at the home visit on 6/28/23, at 11:42 a.m., P4 stated she did not know how to read or write. P4 stated she learned how to sign her name. During a concurrent observation and interview, at the home visit on 6/28/23, at 11:51 a.m., RN 1 was observed providing an agency brochure to the patient. The literature on the brochure was in English. P4 stated her preferred language was Spanish. During a concurrent interview and record review on 6/30/23, at 12:49 p.m., P4s records titled, ";Informed Consent and Treatment Authorization", dated 2/9/23, was reviewed with the administrator (ADM). The record indicated, ";Acknowledgement...Signature"P4s name. The ADM stated P4s preferred language was Spanish and the consents were in English. The ADM stated the consents should be in Spanish so P4 can read the consents if she wants to. The ADM stated she was not aware P4 could not read and write. b). A record review of Patient 5s (P5) ";Personal Information", indicated P5 had a Start of Care (SOC) date of 3/20/2023 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). During an interview on 6/28/23, at 3:10 p.m. P5s Caregiver (CG 2) stated the agency had provided written information about hospice services in English. CG 2stated P5s preferred language was Spanish. The CG stated they could not read English, but their daughter would help them read the information.

Based on interview, observation, and record review, the Hospice Agency (HA) failed to provide written information regarding advance directive (a legal document that outlines person's wishes in the event an individual is unable to express wishes for healthcare and treatments) policies and descriptions for one of six sampled patients (Patient 4). This failure had the potential to result in the patients family and/or caregivers not knowing what the patients medical decisions are, which can result in psychological distress to the patient. --- , A record review of Patient 4s (P4) ";Personal Information", indicated P4 had a Start of Care (SOC) date of 2/9/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. A record review of Patient 4s (P4) ";Personal Information", indicated P4 had a Start of Care (SOC) date of 2/9/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. During a home visit on 6/28/23, at 10:20 a.m. Registered Nurse 1 (RN 1) was observed providing care to P4. During the home visit on 6/28/23, at 11:38 a.m. a lavender folder was observed in P4s home. The folder had the name of the agency. Inside the folder was a copy of P4s plan of care. No other documents in the folder were observed. During an interview, at the home visit on 6/28/23, at 11:42 a.m., P4 stated she did not know how to read or write. P4 stated she learned how to sign her name. During an interview on 6/28/23 at 12:00 p.m., RN 1 stated P4s folder did not have any copies of the documents P4 had signed or any information about the agency and hospice care services. RN 1 stated P4 should have copies of consents she signed because it is a legal document and P4 needed to have information on the services she signed for. RN 1 stated it was P4s right to have copies and information of what she signed. A review of P4s record titled, ";Informed Consent and Treatment Authorization", dated 2/9/23, indicated, ";Advanced Directives I have been provided the following information regarding advance directives." The record indicated the following were not marked: ";Informed of my rights to formulate and Advance Directive. I am not required to have an Advance Directive in order to receive medical treatment by any healthcare provider...".

Based on interview, observation, and record review, the Hospice Agency (HA) failed to inform four of six sampled patients (Patient 1, Patient 2, Patient 4, and Patient 5) about the services they provide and the limitations on those services. This failure resulted in the patient not being aware about what hospice care is and what services are covered while being in hospice. --- , a. A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. During an interview on 6/28/2023 at 12:51 p.m. with P1, P1 was asked what hospice services were. P1 stated, ";They help people that cant, disable people that are unable to pick up their medication. They bring the medication to you. They are very helpful. I didnt have a way to get my medicine." P1 also stated that she was never told that she had six months or less to live. P1 stated, ";I wasnt told that. Thats new to me. No, there has not been a doctor that told me I had six months or less to live. I havent seen the agencys doctor either. I hope he does not come tell me Im going to die soon. I had to go to the urgent care sometime last week because I injured my finger. I called the nurse the next day and told her about it. I guess I was not allowed to do that. (P2) has not been told either." b. A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including chronic obstructive pulmonary disease (COPD-constriction of the airways and difficulty or discomfort in breathing). During an interview on 6/28/2023 at 12:51 p.m. with P2, P2 stated, ";Im sick but no one told me I will die in six months." c. A record review of Patient 4s (P4) ";Personal Information", indicated P4 had a Start of Care (SOC) date of 2/9/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. During a home visit on 6/28/23, at 10:20 a.m. Registered Nurse 1 (RN 1) was observed providing care to P4. During an interview during the home visit on 6/28/23, at 11:15 a.m. P4 stated she did not have a heart disease and her health status was well controlled. During the home visit on 6/28/23, at 11:38 a.m. a lavender folder was observed in P4s home. The folder had the name of the agency. Inside the folder was a copy of P4s plan of care. No other documents in the folder were observed. During an interview, at the home visit on 6/28/23, at 11:42 a.m., P4 stated she did not know how to read or write. P4 stated she learned how to sign her name. During an interview during the home visit on 6/28/23, at 11:50 a.m., P4 stated she did not know what hospice care was. P4 stated she learned about the agency when she was shopping at a local supermarket. The HA was promoting their services outside of the supermarket. P4 stated the HA told her the program would help her get a walker. P4 stated she did not have a terminal illness and a doctor had not told her she had 6 months or less to live. P4 stated the HA did not explain to her Medicare might not cover other health care costs while on hospice care. During an interview on 6/30/23, at 12:49 p.m., the administrator (ADM) stated hospice services were explained to P4 on admission and could not provide an explanation why hospice care information was not in P4s home and why P4 stated she did not have a terminal illness. d. A record review of Patient 5s (P5) ";Personal Information", indicated P5 had a Start of Care (SOC) date of 3/20/2023 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). During an interview on 6/28/23, at 3:10 p.m. P5s Caregiver (CG 2) stated they were referred to the agency by a friend because they were told the agency could help P5 get a wheelchair. CG 2 stated P5 did not have a terminal illness and a doctor had not informed them P5 has 6 months or less to live. During an interview on 6/30/23, at 12:15 p.m., the ADM did not provide an explanation on P5s statement of not having a terminal illness. A review of facilitys public brochure, undated, indicated ";Care is provided by an Interdisciplinary Team of Hospice-trained professional including Physician... Clinical Social Worker, non-denominational chaplains..." A review of facilitys policy and procedure titled, ";Rights/Responsibilities" dated May 2023, indicated ";Each patient will be an active, informed participant in his/her plan of care. 1. The patient, authorized decision-maker... will be informed during the initial assessment visit, in advance of furnishing care, of: C. The right to elect hospice care." A review of facilitys policy and procedure titled, ";Admission Criteria and Process" dated May 2023, indicated ";4. The patient must desire hospice services and be aware of the diagnosis and prognosis."

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participations regarding initial and Comprehensive Assessments of Patients was met as follows : --- , 1. The HA staff failed to conduct and document an accurate initial comprehensive 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 six of six sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). These patients did not have life expectancy of six months or less, and had no documented need for physical, psychosocial, emotional, or spiritual care. (Refer to L 522). 2. The HA failed to ensure the interdisciplinary group complete the comprehensive assessment no later than 5 calendar days after election of hospice care for two of six sampled patients (Patient 5 and Patient 6). (Refer to L 523). 3. The HA failed to identify and address current medical conditions for two of six sampled patients (Patient 1 and Patient 3). Patient 1 visited an urgent care center due to a finger injury and Patient 2 visited an emergency department which diagnosed him with hypoglycemia (low blood sugar). (Refer to L524). 4. The HA failed to ensure four of six sampled patients (Patient 1, Patient 2, Patient 5 and Patient 6) receive an initial bereavement assessment. (Refer to L 531). 5. The HA failed to ensure the interdisciplinary group (IDG) met and updated the comprehensive assessment at least every 15 days for five out of six sample patients (Patient 1, Patient 2, Patient 3, Patient 4, and Patient 5). (Refer to L 533). The cumulative effect of these systemic practices resulted in the hospice agency admitting patients who did not meet admission criteria and did not qualify for the Medicare hospice benefit.

Based on observation, interview and record review the Hospice Agency (HA) staff failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for six of six sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, and Patient 6). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential to result in the patients not receiving appropriate healthcare services that could affect their quality of life. --- , a. A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. A review of P1s ";Visit Note RN (registered Nurse)" dated 6/23/2023, indicated ";SN (skilled nurse) visited patient... confined to bed or chair more than 50% of waking hours, unable to carry on normal activity without shortness of breath, palpitations, or chest pain... Family given instructions on administering pain meds and repositioning patient..." A review of P1s ";Re-cert Assessment" dated 6/2/2023, indicated total number of activities with complete dependence 4 – ambulation, toileting, transfer, and bathing. Musculoskeletal – rigidity and range of motion loss. Mobility – very limited. Activity – chairfast. Environmental Safety – confined to bed or chair-wheelchair, dependent on walker or cane. Narrative & Disease Trajectory – The nurse visited her 1x per week, while the chaplain and social worker visited her once per month... During the 1st-90 days of coverage, the patient experienced and increase in weakness, decreased mobility and worsening hygiene. IDT (Interdisciplinary Team) goals is to keep the patient as... conscious as possible..." During a joint home visit on 6/28/2023 at 10:30 a.m. with the Administrator (ADM) to P1s home, ADM stated that P1s sister is their caregiver and stated, ";She comes here often if they need something, she lives around here, right around the corner." P1 answered the door and invited us in. P1 then ambulated without a cane or walker to the dining room and sat on a dining room chair. P1 stated that she just had some coffee and will be deciding on what to make herself and her husband for breakfast. P1 also stated that she took her high blood pressure medication about an hour ago. ADM stated to P1, ";I know you know your name, the date, where youre at. Im going to take your vitals. Did you take your morning medications?" ADM started taking P1s vital signs. During an interview on 6/30/2023 at 2:02 p.m. with the ADM, the ADM stated that she assessed a patients cognitive level by asking their name, the place and date and time. ADM also stated that during the home visit on 6/28/2023 she did not assess P1s cognitive level. ADM stated, ";I know her, it was by habit, it was my mistake. I assumed because I know her from before." During an interview on 6/28/2023 at 12:51 p.m. with P1, P1 stated that she was not told she had six months or less to live. P1 stated, ";I wasnt told that. Thats new to me. No, there has not been a doctor that told me I had six months or less to live. I havent seen the agencys doctor either. I hope he does not come tell me Im going to die soon. P1 also stated that she went to the urgent care last week because she injured her finger. P1 stated, ";I had to go to the urgent care sometime last week because I injured my finger. The bone was deformed, and they had to put it back in place..." During an interview on 6/29/2023 at 11:50 a.m. with the ADM, the ADM stated she was aware of P1s visit to the urgent care last week. ADM stated, ";she told us, she injured her, I dont recall, it was her toe. (ADM was made aware it was her finger). Oh yeah, she called the office, thats one of the things we want to improve with our communication log. ADM also stated that she did not assess P1s finger yesterday during her home visit, and that there is nothing documented regarding her finger injury. ADM stated, ";I called the doctor, but I did not document that the doctor was made aware." During a concurrent interview and record review on 6/29/2023 at 10:50 a.m. with the Administrator (ADM) of P1s Electronic Medical Record (EMR) form titled ";Comprehensive Nursing Assessment" dated 3/11/2023, ADM stated she was the one who completed and documented P1s initial nursing assessment. The form indicated: -completely dependent on a caregiver when ambulating, toileting, transferring and bathing. ADM stated, ";She needs maximum assistance, it was four, ambulating, toileting, bathing, and transfer." -used a cane with stand by assist and used a walker with moderate assist when ambulating. It also indicated her mobility was very limited. ADM stated. ";She does have a walker and a cane that she uses, yesterday she didnt use it when we were there. She usually does, I dont know why she didnt use anything yesterday." -musculoskeletal rigidity and loss of range of motion. It also indicated that P1 has history of chronic wrist and leg pain. ADM stated, ";yes, mostly the leg that she was complaining of pain. Yes, she does that is why she was complaining of pain in that leg." -Braden risk: chairfast, mobility very limited, moisture occasional moist. ADM stated, ";Yes, she was sitting on her chair yesterday, she is chairbound." -Environmental safety: confined to bed. ADM stated, ";She does stay in bed most of the time. Yes, I would say yes because she stays in bed most of the time. Yesterday, she was not confined to her bed." b. A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including chronic obstructive pulmonary disease (COPD-constriction of the airways and difficulty or discomfort in breathing). During a joint home visit on 6/28/2023 at 10:30 a.m. with the Administrator (ADM) to P2s home, ADM stated that P2s sister-in-law is his caregiver and stated, ";She comes here often if they need something, she lives around here, right around the corner." P2 was noted sitting on single reclining sofa dressed watching television with a nasal canula in nose, receiving oxygen. P2 complained of right lower abdominal pain, ADM assisted P2 pull pants down and assessed pain and skin integrity. P2 noted wearing underwear. During an interview on 6/28/2023 at 12:51 p.m. with P2, P2 stated, ";Im sick but no one told me I will die in six months." During a concurrent interview and record review on 6/29/2023 at 12:30 p.m. with the Administrator (ADM) of P2s Electronic Medical Record (EMR) form titled ";Comprehensive Nursing Assessment" dated 3/11/2023, ADM stated she was the one who completed and documented P2s initial nursing assessment. The form indicated: -frequent soils diaper and wets self ";burdensome to the family such as often he soils his diaper or wets himself requiring frequent incontinence care". ADM stated, ";I know he usually use pull ups; he is both continent and incontinent, if he is incontinent once that means he is incontinent. Just urine, sometimes. I would say no, maybe at nighttime. No, he does not soil himself." ADM also stated, ";He already came to us on oxygen. I dont know how long he was on 02 before us. I did not document that. I didnt document that his 02 saturation goes below 88% on room air." c. A record review of Patient 3s (P3) ";Personal Information", indicated P3 had a Start of Care (SOC) date of 8/8/2022 and End of Care (EOC) date of 12/24/2022, with a primary diagnoses including hypertensive (high blood pressure) heart disease with heart failure. During a concurrent interview and record review on 6/29/2023 at 1 p.m. with the Administrator (ADM) of P3s Electronic Medical Record (EMR), the EMR indicated P3 was seen in an emergency department (ED) and was diagnosed with hypoglycemia (low blood sugar) on 8/24/2022. ADM stated that there was no documentation in P3s EMR indicating his visit to the ED. ADM stated, ";We are supposed to get medical record and do the proper follow up, we need to call the patient and find out about the condition on the patient. There is no communication log. The LVN (Licensed Vocational Nurse) did not mention anything. Nobody followed up on the patients hypoglycemia. It could lead to more complications for the low sugar. He could pass out or fallen." ADM also stated that there is no documentation that P3s doctor was made aware of the ED visit. A review of facilitys policy and procedure titled, ";Comprehensive Assessment" dated May 2023, indicated ";1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including as least the following information, as relevant: E. Current treatment and patient response to that treatment. J. Patients functional status including, but not limited to, the degree of self-care and the amount and level of assistance needed. L. Patients past and present medical and psychological history including pertinent diagnosis and any co-morbidity conditions. M. Name and address of the patients attending physician. 3. The agency must assure that the data elements allow for measurement of outcomes. 4. The clinical supervisor/nursing supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. C. if there has been a change in the patients condition/status then the comprehensive assessment must be updated. d. A record review of Patient 4s (P4) ";Personal Information", indicated P4 had a Start of Care (SOC) date of 2/9/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. During a home visit on 6/28/23, at 10:33 a.m., with Registered Nurse1 (RN 1), P4 was observed walking independently, without the use of assistive device. P4 walked from kitchen to the living room comfortably, breathing normally without distress. During a concurrent observation and interview on 6/28/23, at 11:13 a.m., RN 1 was observed interviewing P4. RN 1 was observed instructing P4 on medication use for chest pain. P4 stated to RN 1 that she has not had to use the medication because she had never experienced chest pain. During an interview during the home visit on 6/28/23, at 11:15 a.m., P4 stated she did not have heart problems and her health status was under control. During an interview during the home visit on 6/28/23, at 11:50 a.m., P4 stated she did not know what hospice care was. P4 stated she did not have a terminal illness and a doctor had not told her she had 6 months or less to live. During an interview on 6/28/23, at 12:00 p.m., RN 1 stated hospice care was for patients who were dying and had 6 months or less to live. RN 1 stated P4 qualified for hospice care due to her diagnosis. When asked if P4 had 6 months or less to live, RN 1 stated, ";she looks good". During an interview on 6/29/23, at 12:06 p.m., the ADM stated the LCD (LCD-Local Coverage Determination, a tool used to determine if patient qualifies for hospice care) was used to determine hospice care criteria. The ADM stated the tool was used for the initial comprehensive assessment. The ADM stated the NYHA IV (NYHA-New York Heart Association, a tool used to classify the extent of heart failure. Class IV-four, means severe limitations, experiences symptoms while at rest, and mostly bed bound), criteria was for patients with advanced heart problems that does not let them be independent. During a concurrent interview and record review on 6/30/23, at 12:34 p.m., P4s record titled, ";Comprehensive Nursing Assessment", dated 2/9/23, was reviewed with the ADM. The record indicated, ";KPS/PPS/FAST/NYHA score effecting ADL? KPS (Karnosfsky Performance Scale-an assessment tool for predicting the length of survival in terminally ill patients) 50, PPS (Palliative Performance Scale-a tool used to assess functioning and disease progression in elderly patients and adults with chronic conditions) 50, NYHA IV. Nature & Condition of Terminal Illness/LCD Eligibility, Illness trajectory and reason for hospice admission. The following conditions exist as evidenced in or reported by medical history, patient, PCG/Family." The ADM stated a KPS score of 50 meant P4 required considerable assistance and frequent medical care; PPS score of 50 meant P4 mainly sits or lays, is unable to do any work, and there is extensive evidence of disease. The ADM stated there was no evidence of extensive disease in P4s record. There was no History and Physical (H&P, a document written by a doctor describing the health history, the current health conditions, and the plan for care) and no medical documents to support P4 had a terminal illness with a life expectancy of 6 months or less to live. During a concurrent interview and record review on 6/30/23, at 12:38 p.m., P4s record titled, ";LCD Hospice Eligibility Determination", dated 2/9/23, was reviewed with the ADM. The record indicated, ";Patient is eligible per LCD Guidelines...Heart Disease 1. Untreatable Condition: 1a. Has patient been ruled out as a candidate for surgical procedures? Yes. 1b. Has patient declined surgical procedures? Yes. 1c.Is patient optimally treated for heart disease with diuretics (medications that help remove water from the body) and vasodilators (medications helping lower blood pressure)? Yes.". The ADM stated she could not recall where she obtained the information to answer ";yes" to questions 1a and 1b. The ADM stated there was no H&P for P4. The ADM stated P 4 was not taking any diuretics. During a concurrent interview and record review on 6/30/23, at 12:38 p.m., P4s record titled, ";LCD Hospice Eligibility Determination", dated 2/9/23, was reviewed with the ADM. The record indicated, ";Heart Disease...2. NYHA classification (condition a must be met) 2a. Does this CHF (Congestive Heart Failure-when the heart cannot pump enough blood to meet the bodys needs) or angina (chest discomfort or shortness of breath caused when the heart does not receive enough oxygen) by patient meet the criteria for NYHA Class IV level? Yes. 2b. Is Ejection fraction (the percentage of blood that is pumped out of a filled ventricle as a result of a heart beat. 20 indicates severe heart failure) <20 (if available) yes.". The ADM stated P4 was showing signs and symptoms of shortness of breath, fatigue, occasional chest pain, and weakness when she was assessed. The ADM stated this is the reason why she documented ";yes" for the NYHA Class IV level. The ADM stated she did not recall the reason why she selected ";yes" for the ejection fraction less than 20. The ADM stated she didnt know if she clicked ";yes" by mistake. When asked if patient was hospice eligible, the ADM stated now that she reviewed each criteria, she would say no. When asked what effect would P4 have from being admitted to hospice care without having a terminal illness, the ADM stated P4 would have limitation on the services she can get in the community. The HA did not have evidence P4 had a terminal illness. e. A record review of Patient 5s (P5) ";Personal Information", indicated P5 had a Start of Care (SOC) date of 3/20/2023 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). During an interview on 6/28/23, at 3:10 p.m. P5s Caregiver (CG 2) stated P5 did not have a terminal illness and a doctor had not informed them P5 had 6 months or less to live. CG 2 stated P5 activities included accompanying her to the market. CG 2 stated the agency had provided oxygen for P5 in case he needed it and was thankful P5 had not had a need for it. CG 2 stated P5 has never used oxygen because he does not have shortness of breath. During a concurrent interview and record review on 6/30/23, at 11:27 a.m., P5s record titled, ";Comprehensive Nursing Assessment", dated 3/20/23, was reviewed with the ADM. The record indicated, ";KPS/PPS/FAST/NYHA score effecting ADL? 50, PPS 50, NYHA IV. Nature & Condition of Terminal Illness/LCD Eligibility, Illness trajectory and reason for hospice admission. The following conditions exist as evidenced in or reported by medical history, patient, PCG/Family." The ADM stated a KPS score of 50 meant P5 required considerable assistance and frequent medical care; PPS score of 50 meant P5 mainly sits or lays, is unable to do any work, and there is extensive evidence of disease. P5s NYHA IV: meant the heard disease makes it unable for the patient to carry on activities without discomfort. The ADM stated P5s H&P talked about his amputation (removal of a limb to prevent worsening of condition), did not indicate evidence of extensive disease, the records did not mention P5 had heart disease, and there was no diagnostic information of medical documents to support a diagnosis of heart disease. The ADM stated the HA determined P5 had heart disease from the medical assessment done by Medical Doctor 4 (MD 4). During a concurrent interview and record review on 6/30/23, at 11:27 a.m., P5s record titled, ";LCD Hospice Eligibility Determination", dated 3/20/23, was reviewed with the ADM. The record indicated, ";Patient is eligible per LCD Guidelines...Heart Disease 1. Untreatable Condition: 1a. Has patient been ruled out as a candidate for surgical procedures? Yes. 1b. Has patient declined surgical procedures? Yes. 1c.Is patient optimally treated for heart disease with diuretics (medications that help remove water from the body) and vasodilators (medications helping lower blood pressure)? Yes.". The ADM stated she could not recall where she obtained the information to answer ";yes" to questions 1a and 1b because the HA did not have medical documents to support the criteria. The ADM stated question 1c. should not have been answered because P5 was not on any diuretic or vasodilator. During a concurrent interview and record review on 6/30/23, at 11:27 p.m., P5s record titled, ";LCD Hospice Eligibility Determination", dated 3/20/23, was reviewed with the ADM. The record indicated, ";Heart Disease...2. NYHA classification (condition a must be met) 2a. Does this CHF or angina by patient meet the criteria for NYHA Class IV level? Yes. 2b. Is Ejection fraction <20 (if available) Yes.". The ADM stated P5 had oxygen to use as needed. When asked if P5 was using oxygen, the ADM stated she did not mention anything about oxygen use in the medical records. D stated she could not recall where she got the information to answer ";yes" to question 2b. The ADM stated the information to answer 2b should be in the medical documents, the HA did not have. The ADM stated the LCD assessment was not accurate. When asked what the qualifying criteria for hospice care was for P5, the ADM stated it was heart disease, but the HA did not have medical documents to support it. The ADM stated P5s admission was inaccurate. The ADM stated the effect of admitting P5 to hospice care, without a terminal illness, was that he would have limited services in the community. The HA did not have evidence P5 had a terminal illness. f. A record review of Patient 6s (P6) ";Personal Information", indicated P6 had a Start of Care (SOC) date of 1/30/2023 and an End of Care (EOC) date of 2/16/2023, with a primary diagnoses including heart failure (when the heart doesnt pump enough blood for the bodys needs). During a concurrent interview and record review on 6/30/23, at 10:45 a.m., P6s record titled, ";Comprehensive Nursing Assessment", dated 1/30/23, was reviewed with the ADM. The record indicated, ";KPS/PPS/FAST/NYHA score effecting ADL? 50, PPS 50, NYHA IV. Nature & Condition of Terminal Illness/LCD Eligibility, Illness trajectory and reason for hospice admission. The following conditions exist as evidenced in or reported by medical history, patient, PCG/Family." The ADM stated a KPS score of 50 meant P6 required considerable assistance and frequent medical care; PPS score of 50 meant P6 mainly sits or lays, is unable to do any work, and there is extensive evidence of disease. The ADM stated extensive evidence of disease meant P6 was fatigued, had chest pain, and decreased mobility. The ADM stated there was no H&P or any other medical documents to support the diagnosis of heart failure. The ADM stated it was important to have medical documents because it can assist the doctor in having a bigger picture about the patients condition. Medical documents help in determining if patient has hospice criteria. During a concurrent interview and record review on 6/30/23, at 10:45 a.m., P6s record titled, ";LCD Hospice Eligibility Determination", dated 1/30/23, was reviewed with the ADM. The record indicated, ";Patient is eligible per LCD Guidelines...Heart Disease 1. Untreatable Condition: 1a. Has patient been ruled out as a candidate for surgical procedures? Yes. 1b. Has patient declined surgical procedures? Yes. 1c.Is patient optimally treated for heart disease with diuretics (medications that help remove water from the body) and vasodilators (medications helping lower blood pressure)? Yes.". The ADM stated she could not remember where she got the information to answer ";yes" for questions 1a and 1b. The ADM stated the LCD hospice assessment was inaccurate because the HA did not have an H&P to reinforce the assessment. The ADM stated P6 did not have hospice care admission criteria. There was no evidence P6 had a terminal illness. During a concurrent interview and record review on 6/30/23, at 10:45 a.m., P6s record titled, ";LCD Hospice Eligibility Determination", dated 1/30/23, was reviewed with the ADM. The record indicated, ";Heart Disease...2. NYHA classification (condition a must be met) 2a. Does this CHF or angina by patient meet the criteria for NYHA Class IV level? Yes. 2b. Is Ejection fraction <20 (if available) Yes.". The ADM stated ";yes" was answered for question 2a because P6 would become very fatigued when walking and would require frequent rest periods. The ADM stated she could not recall where she got the information to answer ";yes" for question 2b. The ADM stated P6s admission was inaccurate. The ADM stated the effect of admitting P5 to hospice care, without a terminal illness, was that he would have limited services in the community. A review of facilitys policy and procedure titled, ";Ongoing Comprehensive Assessment" dated May 2023, indicated ";2. The nurse will assess the patient on each visit, for: I. Mental status K. Functional status. N. Spiritual issues. O. Additional psychosocial issues 4. Based on the assessments, the plan of care – including problems, needs, goals, and outcomes – will be reviewed and updated by the interdisciplinary group members responsible for the case.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group completed the comprehensive assessment no later than five calendar days after election of hospice care for two of six sampled patients (Patient 5 and Patient 6). This deficient practice had the potential to result in patients needs not being identified. --- , 1a.A record review of Patient 5s (P5) ";Personal Information", indicated P5 had a Start of Care (SOC) date of 3/20/2023 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). A review of P5s Electronic Medical Record (EMR) on 6/28/2023 at 8:38 p.m. of form titled ";POC/IDG (Plan of Care/Interdisciplinary Group)" dated 3/20/2023, indicated section ";Chaplain Signature" was left blank. During an interview on 6/29/2023 at 12:15 p.m., the ADM stated the IDG member were the physician, chaplain, social worker, and registered nurse. The ADM also stated that their responsibilities included, ";report about patients conditions, to be updated about the patient changes. They need to document under their discipline, whoever didnt have the chance to participate can go there and read about the patients last update. We know who attended by their signatures in the meeting in (EMR). All the staff is aware about the patient condition that way we can provide a better quality of care." The ADM stated that if one or more members fail to attend a meeting ";The flow of communication will be interfered. The staff might not be aware of any changes or needs." During a concurrent interview and record review on 6/30/23, at 11:24 a.m. P5s record titled, ";POC/IDG review", dated 3/20/23, was reviewed with the administrator ADM. The record indicated, ";IDG Discussion...Spiritual:-SC (spiritual counselor) was informed of patient admission and will be calling the Patient/Family to schedule an appointment for an initial SC visit. Spiritual Care Coordinator for Spiritual Assessment within 5 days of Admission to Identify Spiritual Needs/Support to Patient, Family, and Primary Caregiver." The ADM stated she had composed the note. The ADM stated the SC did not call the patient. The ADM stated P5s spiritual needs were not assessed because the SC needed to have done that. The ADM stated the effect of not having an SC assessment would mean P5 would not be able to benefit from the program, emotional needs might not be met. 1b. During an interview on 6/30/23 at 10:24 a.m., the MSW stated she did not recall doing a psychosocial assessment for P5. During a concurrent interview and record review on 6/30/23, at 11:17 a.m., P5s record titled, ";Psychosocial Assessment", dated 3/23/23, was reviewed with the ADM. The record indicated, ";...7. Narrative...-MSW (Medical Social Worker) evaluation/services declined at this time. MSW will remain available as needed or requested." Further review of the record indicated the ADM signed the document. The ADM stated the MSW did not call. The ADM stated she knew that because she was the one that did the note. The ADM stated the MSW was in the IDG meeting and was informed. The ADM stated she could not recall why she did not call the patient. We do not know the needs of the patient because we didnt call the patient. During an interview on 6/30/23, at 11:21 a.m., the ADM stated the MSW did not call P5. The ADM stated she could not recall the reason why P5 declined the service. The MSW should have called and explained the service to the patient. A review of P5s record titled, ";POC/IDG Review", dated 3/20/23, indicated, ";IDG Discussion...Psychosocial:-MSW (medical social worker) was informed of patient admission and will be calling the Patient/Family to schedule an appointment for an initial MSW visit. Medical Social Worker Evaluate and Assess for needs initial evaluation within 5 days of admission for Psycho-Social Counseling and Support." 2a.A record review of Patient 6s (P6) ";Personal Information", indicated P6 had a Start of Care (SOC) date of 1/30/2023 and an End of Care (EOC) date of 2/16/2023, with a primary diagnoses including heart failure (when the heart doesnt pump enough blood for the bodys needs). During an interview on 6/29/23, at 10:20 a.m., the (MSW) stated the importance of doing a psychosocial assessment for a hospice patient was to identify their physical, emotional, and community needs. People are vulnerable, there are needs that need to be addressed. The MSW stated if there was no documentation of a psychosocial assessment on P6s record it meant she did not do it. During a concurrent interview and record review on 6/30/23, at 10:32 a.m., P6s medical records were reviewed with the ADM. The ADM state there was no note indicating the MSW called the patient. The purpose of calling the patient was to explain about the psychosocial service. The ADM stated it was the responsibility of the MSW to call and explain the service. The ADM stated the importance for the MSW to do a psychosocial assessment was part of her duties and responsibilities as an MSW, best one to explain about the service and what benefits the patient can have of the service. During a concurrent interview and record review on 6/30/23, at 10:36 a.m., P6s record titled, ";Psychosocial", dated 2/2/23, was reviewed with the ADM. The record indicated, ";...7. Narrative...-MSW evaluation/services declined at this time. MSW will remain available as needed or requested." Further review of the record indicated the ADM signed the document. The ADM stated she could not recall the reason why she filled out the document: it should have been the MSW. The ADM stated she explained had explained the service to P6, and should have been the MSW because that is the best person to explain services to the patient. A review of P6s record titled, ";POC/IDG Review", dated 1/30/23, indicated, ";IDG Discussion...Psychosocial:-MSW was informed of patient admission and will be calling the patient/Family to schedule an appointment for an initial MSW visit. Medical Social Worker Evaluate and Assess for needs initial evaluation within 5 days of admission for Psycho-Social Counseling and Support." Further review of the record indicated, on 1/30/23, the MSW signed the document. 2b.During a concurrent interview and record review on 6/30/23, at 10:40 a.m. P6s record titled, ";POC/IDG review", dated 1/30/23, was reviewed with the ADM. The record indicated, ";IDG Discussion...Spiritual:-SC (spiritual counselor) was informed of patient admission and will be calling the Patient/Family to schedule an appointment for an initial SC visit. Spiritual Care Coordinator for Spiritual Assessment within 5 days of Admission to Identify Spiritual Needs/Support to Patient, Family, and Primary Caregiver." Further review of the record indicated, on 1/30/23, the SC signed the document. The ADM stated the SC should have been the one calling the patient because he is the best one to explain what SC services are and what benefits the patient can have from the service. The ADM stated there was no note to indicate a call was made to the patient. The ADM stated the effect of not having an SC assessment was the Patient and or family will not be able to receive spiritual care and spiritual needs are not met. During a concurrent interview and record review on 6/30/23, at 10:42 a.m., P6s record titled, ";Spiritual Assessment", dated 2/1/23, was reviewed with the ADM. The record indicated, ";...6. Care Provided & Narrative...-SC evaluation/services declined at this time. SC will remain available as needed or requested." Further review of the record indicated the ADM signed the document. The ADM stated she had composed the note. The ADM stated it was hard to recall what happened. The note doesnt say what was explained to the patient and the reason the patient declined. The note doesnt tell the story. The ADM stated the chaplain, or the person who actually provided the service should be documenting the note.

Based on interview and record review the Hospice Agency failed to identify and address the current medical conditions for two of six sampled patients (Patient 1 and Patient 3). Patient 1 visited an urgent care center due to a finger injury and Patient 3 visited an emergency department which diagnosed him with hypoglycemia (low blood sugar). This failure resulted in patients not being treated or assessed for possible physical or emotional complications. --- , a. A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. During an interview on 6/28/2023 at 12:51 p.m. with P1, P1 stated that she went to the urgent care last week because she injured her finger. P1 stated, ";I had to go to the urgent care sometime last week because I injured my finger. The bone was deformed, and they had to put it back in place..." During an interview on 6/29/2023 at 11:50 a.m. with the ADM, the ADM stated she was aware of P1s visit to the urgent care last week. ADM stated, ";she told us, she injured her, I dont recall, it was her toe. (ADM was made aware it was her finger). Oh yeah, she called the office, thats one of the things we want to improve with our communication log. ADM also stated that she did not assess P1s finger yesterday during her home visit, and that there is nothing documented regarding her finger injury. ADM stated, ";I called the doctor, but I did not document that the doctor was made aware." c. A record review of Patient 3s (P3) ";Personal Information", indicated P3 had a Start of Care (SOC) date of 8/8/2022 and End of Care (EOC) date of 12/24/2022, with a primary diagnoses including hypertensive (high blood pressure) heart disease with heart failure. During a concurrent interview and record review on 6/29/2023 at 1 p.m. with the Administrator (ADM) of P3s Electronic Medical Record (EMR), the EMR indicated P3 was seen in an emergency department (ED) and was diagnosed with hypoglycemia (low blood sugar) on 8/24/2022. ADM stated that there was no documentation in P3s EMR indicating his visit to the ED. ADM stated, ";We are supposed to get medical record and do the proper follow up, we need to call the patient and find out about the condition on the patient. There is no communication log. The LVN (Licensed Vocational Nurse) did not mention anything. Nobody followed up on the patients hypoglycemia. It could lead to more complications for the low sugar. He could pass out or fallen." ADM also stated that there is no documentation that P3s doctor was made aware of the ED visit. A review of facilitys policy and procedure titled, ";Comprehensive Assessment" dated May 2023, indicated ";1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including as least the following information, as relevant: E. Current treatment and patient response to that treatment. L. Patients past and present medical and psychological history including pertinent diagnosis and any co-morbidity conditions. C. if there has been a change in the patients condition/status then the comprehensive assessment must be updated." A review of facilitys policy and procedure titled, ";Ongoing Comprehensive Assessment" dated May 2023, indicated ";2. The nurse will assess the patient on each visit, for: I. Mental status K. Functional status. N. Spiritual issues. O. Additional psychosocial issues 4. Based on the assessments, the plan of care – including problems, needs, goals, and outcomes – will be reviewed and updated by the interdisciplinary group members responsible for the case." A review of facilitys policy and procedure titled, ";Monitoring Patients Response/Reporting to Physician" dated May 2023, indicated ";The patients physician and/or the hospice Medical Director will be contacted on the same day when any of the following occur: A. changes in the patients condition F. Changes occur regarding diagnosis, prognosis, or treatment... 4. All conferences or attempts to communicate with the attending physician and/or hospice Medical Director will be documented in the clinical record. 7. The plan of care will be updated according to hospice policies and procedures."

Based on interview and record review the Hospice Agency failed to ensure four of six sampled patients (Patient 1, Patient 2, Patient 5, and Patient 6) receive an initial bereavement assessment. This failure had the potential to result in the patients family and/or caregivers to not be assessed for factors that may place them at risk for a significantly negative bereavement experience. --- , a. A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. A review of P1s medical record form titled, ";Comprehensive Nursing Assessment" dated 3/11/2023, indicated ";MSW (Medical Social Worker) will call the patient and family within 5 days to render initial assessment. SC (Spiritual Counselor will call the patient and family within 5 days to render initial assessment." Under the ";Narrative & Disease Trajectory" indicated ";It was determined that she would benefit from Psycho-social counseling and Spiritual support as part of Hospice care services." A review of P1s medical record form titled, ";Bereavement Assessment" dated 3/14/2023, indicated form was left blank, except for the ";Narrative" section. Under the ";Narrative" section it indicated ";BC (Bereavement Counseling) evaluation/services declined at this time. BC will remain available as needed or requested." The form also indicated it was signed by the Administrator (ADM). During a concurrent interview and record review on 6/29/2023 at 10;50 a.m. p.m. with the ADM, of P1s Electronic Medical Record (EMR), the EMR indicated the initial bereavement assessment was not documented. ADM stated, ";She refused the social worker; the social worker has always been doing it." During a concurrent telephone interview and record review on 6/29/2023 at 1:49 p.m. with the MSW, of P1s EMR, the MSW stated that she completes an initial bereavement assessment if she is notified and assig to a patient. MSW stated, ";I also see a declination note, let me open it up. Also not signed by me, I dont know what happened there. I dont remember what happened in March. If I make a note, I usually sign them." b. A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including chronic obstructive pulmonary disease (COPD-constriction of the airways and difficulty or discomfort in breathing). A review of P2s medical record form titled, ";Comprehensive Nursing Assessment" dated 3/11/2023, indicated ";MSW (Medical Social Worker) will call the patient and family within 5 days to render initial assessment. SC (Spiritual Counselor will call the patient and family within 5 days to render initial assessment." Under the ";Narrative & Disease Trajectory" indicated ";Based on his initial assessment, it was determined that he would benefit from Psycho-social counseling and Spiritual support as part of Hospice care services." A review of P2s medical record form titled, ";Bereavement Assessment" dated 3/14/2023, indicated under the ";Narrative" section ";BC (Bereavement Counseling) evaluation/services declined at this time. BC will remain available as needed or requested." The form also indicated it was signed by the Administrator (ADM). During a concurrent interview and record review on 6/29/2023 at 2;30 p.m. with the ADM, of P2s EMR, the EMR indicated the initial bereavement assessment was not documented. ADM stated, ";He refused when I did my initial assessment. There is no documentation the social worker reached out to him. There should be a note by the social worker, that would be the proof that it was done." During a concurrent telephone interview and record review on 6/29/2023 at 1:49 p.m. with the MSW, of P2s EMR, the MSW stated that she completes an initial bereavement assessment if she is notified and assig to a patient. MSW stated, ";I do have (P2). It was declined. Im just looking at my notes. Thats not my signature. I probably made that note but I didnt sign, I usually sign the notes. This one Im not sure why I didnt." During an interview on 6/28/2023 at 11:50 a.m. with the ADM, the ADM stated, ";We offer them a social worker and a chaplain. We let them know that the social worker and chaplain are available, and they will call them to make an appointment to see them. I expect the social worker and chaplain to call and let them know they are available. They explain their services. They are more able to, I only emphasize to the patients that they are available. The social worker is responsible for the bereavement part. I usually briefly tell the patients that bereavement is available. The social worker is the best to explain to them the bereavement part. Bereavement assessment begins within 5 days of admission." During an interview on 6/29/2023 at 10:50 a.m. with the Administrator (ADM), the ADM stated that the initial bereavement assessment should be completed by the social worker within five days of patients admission. ADM stated, ";Just to explain, I know social worker explains the whole concept. It helps them to accept the disease process and helps them cope with the meaning of the illness. On admission I just let the patient know that the social worker and spiritual counselor are available." ADM also stated that if patients do not have a bereavement assessment, ";Its going to be harder for them to actually, accept the whole diagnosis or cope with the diagnosis." ADM stated that office personnel inform the social worker about a new patient, they are assigned, and they are responsible for calling the patient and or family. They call the social worker and Chaplin with every new admission. Once the social worker and chaplain know about a new admission, they need to contact the patient within 5 days of admission." During a telephone interview on 6/28/2023 at 12:11 p.m. with the Medical Social Worker (MSW), the MSW stated, ";They call me when they need me, then I get assigned to patients. I assess patients psychosocial and environmental needs. I educate them, I provide community resources if they need them. I do comprehensive assessments, recertification assessment, and follow ups as needed." During an interview on 6/29/2023 at 1 p.m. with the Administrator (ADM), ADM stated, ";the hospice responsibility was to provide the bereavement upon admission..." During a telephone interview on 6/30/2023 at 10:15 a.m. with the MSW, the MSW stated, ";if I would do the initial or contact them it would be under the psychosocial assessment. If its not there, that means it was not done. Psychosocial assessment, when someone is on hospice care not only their physical needs, but they also need community and additional support. Theres a lot of things that happen when you get sick, and thats important to address." c.A record review of Patient 5s (P5) ";Personal Information", indicated P5 had a Start of Care (SOC) date of 3/20/2023 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). During a concurrent interview and record review on 6/30/23, at 12:15 p.m. P5s record titled, ";Bereavement Assessment", dated 3/23/23, was reviewed with the ADM. The record indicated, ";...4.Narrative -BC evaluation/services declined at this time. BC will remain available as needed or requested." Further review of the record indicated the ADM had signed the document. The ADM stated the MSW should have done the bereavement assessment because she is able to explain what the bereavement program is about. The ADM stated she could not recall the reason patient declined bereavement services. The ADM stated the purpose of the bereavement assessment purpose was to assist the patient and family with the grieving process, to identify the grieving needs. The ADM stated the HA did not know what P5s patient and family grieving needs are because an assessment was not done. d. A record review of Patient 6s (P6) ";Personal Information", indicated P6 had a Start of Care (SOC) date of 1/30/2023 and an End of Care (EOC) date of 2/16/2023, with a primary diagnoses including heart failure (when the heart doesnt pump enough blood for the bodys needs). During a concurrent interview and record review on 6/30/23, at 12:18 p.m. P6s record titled, ";Bereavement Assessment", dated 2/2/23, was reviewed with the ADM. The record indicated, ";...4.Narrative -BC evaluation/services declined at this time. BC will remain available as needed or requested." Further review of the record indicated the ADM had signed the document. The ADM stated the MSW should have done the bereavement assessment because she is able to explain what the bereavement program is about. The ADM stated she could not recall the reason P6 declined bereavement services. The ADM stated the purpose of the bereavement assessment purpose was to assist the patient and family with the grieving process, to identify the grieving needs. The ADM stated the HA did not know what P6s patient and family grieving needs are because an assessment was not done. A review of facilitys public brochure, undated, indicated ";Care is provided by an Interdisciplinary Team of Hospice-trained professional including Physician... Clinical Social Worker, non-denominational chaplains..." A review of facilitys policy and procedure titled, ";Bereavement Services" dated May 2023, indicated ";1. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Information gathered will be incorporated into the plan of care and considered in the bereavement plan of care." A review of facilitys policy and procedure titled, ";Initial Assessment" dated May 2023, indicated ";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." A review of facilitys policy and procedure titled, ";Bereavement Assessment" dated May 2023, indicated ";On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the bereavement coordinator. The bereavement coordinator will review the bereavement risk assessment to determine potential needs of the survivors. Bereavement needs will be reassessed during each contact. After death occurs, the hospice social worker or bereavement coordinator will complete the bereavement follow-up assessment.... The bereavement coordinator will document the interventions on the bereavement services checklist."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG) met and updated the comprehensive assessment at least every 15 days for five out of six sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4 and Patient 5). This deficient practice had the potential to result in harm if patients are prevented from reaching their goals, due to IDG not addressing changes in the patient's condition. --- , a. A record review of Patient 1s (P1) ";Personal Information" indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. During an interview on 6/28/2023 at 12:51 p.m. with P1, P1 stated that she went to the urgent care last week because she injured her finger. P1 stated, ";I had to go to the urgent care sometime last week because I injured my finger. The bone was deformed, and they had to put it back in place..." A review of P1s medical record form titled, ";POC/IDG (Plan of Care/Interdisciplinary Group) Review" dated 6/22/2023, indicated there was no documentation of P1s visit to the urgent care. It also indicated section physician discussion and Chaplain signature were left blank. During an interview on 6/29/2023 at 11:50 a.m. with the ADM, the ADM stated she was aware of P1s visit to the urgent care last week. ADM stated, ";she told us, she injured her, I dont recall, it was her toe. (ADM was made aware it was her finger). Oh yeah, she called the office, thats one of the things we want to improve with our communication log. ADM also stated that she did not assess P1s finger yesterday during her home visit, and that there is nothing documented regarding her finger injury. ADM stated, ";I called the doctor, but I did not document that the doctor was made aware." During a concurrent interview and record review on 6/29/2023 at 12:15 p.m. with the Administrator (ADM), of P1s Electronic Medical Record (EMR) form titled ";POC/IDG Review" dated 6/2/2023 and 6/22/2023, the form indicated section Chaplain Signature were left blank. ADM stated, ";The chaplain was missing in both; he did not attend the IDG." During a concurrent interview and record review on 6/29/2023 at 12:15 p.m. with the ADM, of P1s EMR form titled ";POC/IDG Review" dated 3/30/2023 and 6/22/2023, the form indicated section discussion – physician, were left blank. ADM stated, ";He should have put something there." b. A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including chronic obstructive pulmonary disease (COPD-constriction of the airways and difficulty or discomfort in breathing). A review of P2s medical record form titled, ";POC/IDG (Plan of Care/Interdisciplinary Group) Review" dated 6/22/2023, indicated section physician discussion and Chaplain signature were left blank. During a concurrent interview and record review on 6/29/2023 at 12:30 p.m. with the ADM, of P2s EMR form titled ";POC/IDG Review" dated 6/22/2023, the form indicated section discussion – physician, were left blank. ADM stated, ";The physician was missing his input, again he should have put something in there." The form also indicated section Chaplain Signature was left blank. ADM stated, ";Not everybody attended, the chaplain is missing." c. A record review of Patient 3s (P3) ";Personal Information", indicated P3 had a Start of Care (SOC) date of 8/8/2022 and End of Care (EOC) date of 12/24/2022, with a primary diagnoses including hypertensive (high blood pressure) heart disease with heart failure. During a concurrent interview and record review on 6/29/2023 at 1 p.m. with the Administrator (ADM) of P3s Electronic Medical Record (EMR), the EMR indicated P3 was seen in an emergency department (ED) and was diagnosed with hypoglycemia (low blood sugar) on 8/24/2022. ADM stated that there was no documentation in P3s EMR indicating his visit to the ED. ADM stated, ";We are supposed to get medical record and do the proper follow up, we need to call the patient and find out about the condition on the patient. There is no communication log. The LVN (Licensed Vocational Nurse) did not mention anything. Nobody followed up on the patients hypoglycemia. It could lead to more complications for the low sugar. He could pass out or fallen." ADM also stated that there is no documentation that P3s doctor was made aware of the ED visit. During an interview on 6/29/2023 at 12:15 p.m. with the Administrator (ADM), the ADM stated the IDG member were the physician, chaplain, social worker, and registered nurse. ADM also stated that their responsibilities included, ";report about patients conditions, to be updated about the patient changes. They need to document under their discipline, whoever didnt have the chance to participate can go there and read about the patients last update. We know who attended by their signatures in the meeting in (EMR). All the staff is aware about the patient condition that way we can provide a better quality of care." ADM also stated that if one or more members fail to attend a meeting ";The flow of communication will be interfered. The staff might not be aware of any changes or needs." d. A record review of Patient 4s (P4) ";Personal Information", indicated P4 had a Start of Care (SOC) date of 2/9/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. During an interview, at the home visit on 6/28/23, at 11:32 a.m., P 4 stated she had been having hearing issues since July 2023. During an interview, at the home visit on 6/28/23, at 11:42 a.m., P4 stated she did not know how to read or write. P4 stated she learned how to sign her name. During an interview on 6/30/23, at 12:49 p.m., the administrator (ADM) stated she was not aware P4 could not read and write. During a concurrent interview and record review on 6/30/23, at 12:49 p.m., P4s electronic medical record was reviewed with the ADM. The ADM stated there was no evidence the IDG group had met to discuss P4s sensory need (hearing issues) and inability to read or write. The ADM stated it was important to discuss P4s need because it would require the IDG team to modify the plan of care and the resources would have to be provided according to P4s need. e. (a) A record review of Patient 5s (P5) ";Personal Information", indicated P5 had a Start of Care (SOC) date of 3/20/2023 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). During an interview on 6/28/23, at 3:10 p.m. P5s Caregiver (CG) Registered Nurse 1 (RN 1) was providing wound care for P5. During a concurrent interview and record review on 6/30/23, at 11:37 a.m., P5s medical record titled, ";POC/IDG Review", dated 5/25/23, was reviewed with the ADM. The ADM stated the record did not indicate the IDG team had discussed the care being provided to P5s wound. The ADM stated the IDG needed to have discussed the dressing changes and monitoring the condition of the wound. The ADM stated it was important to discuss P5s wound so all staff is updated on the condition of the patient. During a concurrent interview and record review on 6/30/23, at 11:49 a.m., P5s medical record titled, ";POC/IDG Review", dated 6/5/23, was reviewed with the ADM. The ADM stated the IDG did not address the wound management for P5. If the IDG is not discussing the wound management, the staff member will not be updated about the current condition of the patient. If we dont know the condition, we cannot update the plan of care. During a concurrent interview and record review on 6/30/23, at 11:49 a.m., P5s medical record titled, ";POC/IDG Review", dated 6/8/23, was reviewed with the ADM. The ADM stated the IDG did not address the wound management for P5. (b) During an interview on 6/29/23, at 11:51 a.m., the ADM stated the purpose of the IDG meeting was to be updated about changes in patients conditions. The ADM stated the IDG members needed to document their input under their own discipline in the electronic medical record (EMR). The importance of documenting the input is for staff to be updated about the lates condition of the patients. The ADM stated validation of IDG members attendance was their signature in the EMR. During a concurrent interview and record review on 6/30/23, at 11:37 a.m., P5s record titled, ";POC/IDG Review", dated 5/25/23, was reviewed with the ADM. The record did not indicate the spiritual counselor had signed the document. The ADM stated the spiritual counselor should have signed the document on the day the meeting was held. During a concurrent interview and record review on 6/30/23, at 11:49 a.m., P5s record titled, ";POC/IDG Review", dated 6/5/23, was reviewed with the ADM. The record did not indicate the doctor, registered, and spiritual counselor had signed the document. The ADM stated if their signature was not in the document, it meant they had not attended the meeting. The ADM stated the importance of attendance was so all members are informed about the patients condition. During a concurrent interview and record review on 6/30/23, at 11:51 a.m., P5s record titled, ";POC/IDG Review", dated 6/8/23, was reviewed with the ADM. The record did not indicate the spiritual counselor had signed the document. The ADM stated the spiritual counselor did not attend the meeting because the signature was not there and there was no notes under ";IDG Discussion...Spiritual". A review of facilitys policy and procedure titled, ";Initial Assessment" dated May 2023, indicated ";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." A review of facilitys policy and procedure titled, ";Comprehensive Assessment" dated May 2023, indicated ";1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including as least the following information, as relevant: 5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days. B. If no changes are needed, then that must be documented. C. if there has been a change in the patients condition/status then the comprehensive assessment must be updated. A review of facilitys policy and procedure titled, ";Ongoing Comprehensive Assessment" dated May 2023, indicated ";2. The nurse will assess the patient on each visit... 4. Based on the assessments, the plan of care – including problems, needs, goals, and outcomes – will be reviewed and updated by the interdisciplinary group members responsible for the case. A review of facilitys policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" dated May 2023, indicated ";the interdisciplinary team/group will collaborate with the patients attending physician to develop a patient-direct plan of care. 1. The hospice interdisciplinary team/group members will include, at a minimum: A. Physician D. Pastoral or other counselor. 2. The interdisciplinary group will: A. Participate in the periodic review and updating of the plan of care for each patient and family receiving hospice services. B. Participate in the periodic review and updating of the plan of care for each patient and family receiving hospice services." A review of facilitys policy and procedure titled, ";The Plan of Care" dated May 2023, indicated ";The Plan of Care will identify the patients needs and services to meet those needs... The individualize plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care. 8. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments... 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... 10. Any changes in the patients condition must result in a change in the plan of care, prior to implementation of the new service. 14. Care provided to the patient will be in accordance with the plan of care.

Based on interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation regarding care planning and coordination of services for patients was met as follows: --- , 1. The HA failed to ensure three of six sampled patients (Patient 1, Patient 3, and Patient 5) plan of care (POC – an individualized plan that maps out the needs and services supplied to patient and their care givers) were reviewed and updated to reflect the most current plans of treatment. Patient 1 was seen and treated at an urgent care and Patient 3 was seen and treated at an emergency department. (Refer to L552). 2. The HA failed to ensure all care services furnished followed individualized plans of care (POC – an individualized plan that maps out the needs and services supplied to patient and their care givers) established be the interdisciplinary team (IDT) by not conducting home visits as indicated in the plan of care for three of six sampled patients (Patient 1, Patient 2, and Patient 3). (Refer to L555). These deficient practices resulted in the HA not providing the services/care as ordered 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 HA failed to ensure three of six sampled patients (Patient1, Patient 3, and Patient 5) plan of care (POC – an individualized plan that maps out the needs and services supplied to patient and their care givers) were reviewed and updated to reflect the most current plans of treatment. Patient 1 was seen and treated at an urgent care. Patient 3 was seen and treated at an emergency department. Patient 5 was receiving wound care without a doctors order. This failure had the potential to result in patients not receiving current treatments/medications as ordered or receiving treatment/medications when not ordered. --- , a. A record review of Patient 1s (P1) ";Personal Information" indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. During an interview on 6/28/2023 at 12:51 p.m. with P1, P1 stated that she went to the urgent care last week because she injured her finger. P1 stated, ";I had to go to the urgent care sometime last week because I injured my finger. The bone was deformed, and they had to put it back in place..." A review of P1s medical record form titled, ";POC/IDG (Plan of Care/Interdisciplinary Group) Review" dated 6/22/2023, indicated there was no documentation of P1s visit to the urgent care. It also indicated section physician discussion and Chaplain signature were left blank. During an interview on 6/29/2023 at 11:50 a.m. with the ADM, the ADM stated she was aware of P1s visit to the urgent care last week. ADM stated, ";she told us, she injured her, I dont recall, it was her toe. (ADM was made aware it was her finger). Oh yeah, she called the office, thats one of the things we want to improve with our communication log. ADM also stated that she did not assess P1s finger yesterday during her home visit, and that there is nothing documented regarding her finger injury. ADM stated, ";I called the doctor, but I did not document that the doctor was made aware." During a concurrent interview and record review on 6/29/2023 at 12:15 p.m. with the Administrator (ADM), of P1s Electronic Medical Record (EMR) form titled ";POC/IDG Review" dated 6/2/2023 and 6/22/2023, the form indicated section Chaplain Signature were left blank. ADM stated, ";The chaplain was missing in both; he did not attend the IDG." During a concurrent interview and record review on 6/29/2023 at 12:15 p.m. with the ADM, of P1s EMR form titled ";POC/IDG Review" dated 3/30/2023 and 6/22/2023, the form indicated section discussion – physician, were left blank. ADM stated, ";He should have put something there." b. A record review of Patient 3s (P3) ";Personal Information", indicated P3 had a Start of Care (SOC) date of 8/8/2022 and End of Care (EOC) date of 12/24/2022, with a primary diagnoses including hypertensive (high blood pressure) heart disease with heart failure. During a concurrent interview and record review on 6/29/2023 at 1 p.m. with the Administrator (ADM) of P3s Electronic Medical Record (EMR), the EMR indicated P3 was seen in an emergency department (ED) and was diagnosed with hypoglycemia (low blood sugar) on 8/24/2022. ADM stated that there was no documentation in P3s EMR indicating his visit to the ED. ADM stated, ";We are supposed to get medical record and do the proper follow up, we need to call the patient and find out about the condition on the patient. There is no communication log. The LVN (Licensed Vocational Nurse) did not mention anything. Nobody followed up on the patients hypoglycemia. It could lead to more complications for the low sugar. He could pass out or fallen." ADM also stated that there is no documentation that P3s doctor was made aware of the ED visit. During an interview on 6/29/2023 at 12:15 p.m. with the Administrator (ADM), the ADM stated the IDG member were the physician, chaplain, social worker, and registered nurse. ADM also stated that their responsibilities included, ";report about patients conditions, to be updated about the patient changes. They need to document under their discipline, whoever didnt have the chance to participate can go there and read about the patients last update. We know who attended by their signatures in the meeting in (EMR). All the staff is aware about the patient condition that way we can provide a better quality of care." ADM also stated that if one or more members fail to attend a meeting ";The flow of communication will be interfered. The staff might not be aware of any changes or needs." c.A record review of Patient 5s (P5) ";Personal Information", indicated P5 had a Start of Care (SOC) date of 3/20/2023 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). During an interview on 6/28/23, at 3:10 p.m. P5s Caregiver (CG) Registered Nurse 1 (RN 1) was providing wound care for P5. During a concurrent interview and record review on 6/30/23, at 11:37 a.m. P5s record titled, ";POC (Plan of Care) Summary", printed on 6/27/23, was reviewed with the ADM. The record did not indicate wound treatment orders. The ADM stated P5s wound care was not specified in the plan of care and was not written down in the orders. There should have been specific order for the wound care. When asked the reason for not having wound care orders, the ADM stated, ";we lack in that area. We have not put an actual order that is a deficiency." The ADM stated there was no documented evidence the doctor was aware of the wound and orders were provided for the wound management of P5. The ADM stated the POC needed to have the doctors order for wound management so the nurse providing care will have better instructions on how to provide the wound care. A review of facilitys policy and procedure titled, ";Initial Assessment" dated May 2023, indicated ";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." A review of facilitys policy and procedure titled, ";Comprehensive Assessment" dated May 2023, indicated ";1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including as least the following information, as relevant: 5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days. B. If no changes are needed, then that must be documented. C. if there has been a change in the patients condition/status then the comprehensive assessment must be updated. A review of facilitys policy and procedure titled, ";Ongoing Comprehensive Assessment" dated May 2023, indicated ";2. The nurse will assess the patient on each visit... 4. Based on the assessments, the plan of care – including problems, needs, goals, and outcomes – will be reviewed and updated by the interdisciplinary group members responsible for the case. A review of facilitys policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" dated May 2023, indicated ";the interdisciplinary team/group will collaborate with the patients attending physician to develop a patient-direct plan of care. 1. The hospice interdisciplinary team/group members will include, at a minimum: A. Physician D. Pastoral or other counselor. 2. The interdisciplinary group will: A. Participate in the periodic review and updating of the plan of care for each patient and family receiving hospice services. B. Participate in the periodic review and updating of the plan of care for each patient and family receiving hospice services." A review of facilitys policy and procedure titled, ";The Plan of Care" dated May 2023, indicated ";The Plan of Care will identify the patients needs and services to meet those needs... The individualize plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care. 8. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments... 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... 10. Any changes in the patients condition must result in a change in the plan of care, prior to implementation of the new service. 14. Care provided to the patient will be in accordance with the plan of care.

Based on interview and record review the Hospice Agency (HA) failed to ensure all care services furnished followed the individualized plan of care established by the interdisciplinary team (IDT) by failing to conduct home visits as indicated in the plan of care (POC – an individualized plan that maps out the needs and services supplied to patient and their caregivers) for three of six sampled patients (Patient 1, Patient 2, Patient 3). This deficient practice resulted in the patients not receiving care/services and placed the patients at risk by not being provided care/services when needed. --- , a. A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. A review of P1s medical record form titled ";POC (Plan of Care) Summary" dated 6/22/2023, indicated ";SN (Skilled Nurse) 1 per week + 1 PRN (as needed) visits..." During a concurrent interview and record review on 6/29/2023 at 10:50 a.m. with the Administrator (ADM), of P1s Electronic Medical Record (EMR), the EMR indicated there were no documented SN visit notes for the week of 5/28/2023. b. A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including chronic obstructive pulmonary disease (COPD-constriction of the airways and difficulty or discomfort in breathing). A review of P2s medical record form titled ";POC Summary" dated 6/22/2023, indicated ";SN (Skilled Nurse) 1 per week + 1 PRN (as needed) visits..." During a concurrent interview and record review on 6/29/2023 at 1 p.m. with the ADM, of P2s EMR, the EMR indicated there were no documented SN visit notes for weeks 5/28/2023, 6/11/2023, and 6/18/2023. ADM stated, ";There was a missed visit, I dont recall all the patients. There is no communication documentation why the visit was missed." c. A record review of Patient 3s (P3) ";Personal Information", indicated P3 had a Start of Care (SOC) date of 8/8/2022 and End of Care (EOC) date of 12/24/2022, with a primary diagnoses including hypertensive (high blood pressure) heart disease with heart failure. A review of P3s medical record form titled ";Comprehensive Nursing Assessment" dated 8/8/2022, indicated ";Need for Hospice Aide – grooming – linen change...; CHHA (Certified Home Health Aide) services: 2x/week." A review of P3s medical record form titled ";POC Summary" dated 12/22/2022, indicated ";SN (Skilled Nurse) 1 per week + 1 PRN (as needed) visits..." During a concurrent interview and record review on 6/29/2023 at 1 p.m. with the ADM, of P3s EMR, the EMR indicated there were no documented SN visit notes for weeks 10/30/2022 and 12/11/2022. ADM stated, ";There are some missed visit. There is no documentation as to why the visits were missed." It also indicated there were no documented CHHA visit notes for the week of 9/4/2022. ADM stated, ";There was a CHHA missed visit, there is no documentation that states why the visit was missed." ADM stated P3 received CHHA services twice a week from 8/2022 to September 2022 and SN services from 8/2022 till discharge. During an interview on 6/29/2023 at 10:50 a.m. with the Administrator (ADM), the ADM stated, ";We document that there was a missed visit and the reason why. I reinforce the importance of visit; we inform the doctor and possible reschedule for another day. Within 24 hours of the visit notes are supposed to be documented. They are to be in (EMR) within the 24 hours." ADM also stated that it was important to document visit notes, ";to be on time, the moment that you do the visit you document. To be on time." A review of facilitys policy and procedure titled, ";Missed Visits" dated May 2023, indicated ";If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week... If a visit is missed and not rescheduled the clinician will: B. Document in the patients clinical record the following information: 2. Date and type of visit that was missed 3. Reason for the missed visit 6. Other person(s) that were notified of the missed visit... If an aide visit is missed the aide will contact the case manager or clinical supervisor..." A review of facilitys policy and procedure titled, ";The Plan of Care" dated May 2023, indicated ";The Plan of Care will identify the patients needs and services to meet those needs... 8. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments... 14. Care provided to the patient will be in accordance with the plan of care." A review of facilitys policy and procedure titled, ";Entries into the Clinical Record" dated May 2023, indicated ";Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. 1. A clinical record... will include at a minimum: J. Reason for interruption in the provision of care and services. 6. Entries into the clinical record will be made on the date care is provided to the patient. All documentation will be turned in to the office within seven (7) days." A review of facilitys policy and procedure titled, ";Clinical Data Collection Review" undated, indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Core Services was met as evidenced by: --- , 1. The HA failed to ensure two of six sampled patients (Patient 1 and Patient 2) had their terminal illness managed and overseen by a physician. (Refer to L590). 2. The HA failed to ensure it provided core services, by not ensuring the Medical Social Worker (MSW) was a facility employee. It also failed to assure the Baccalaureate Social Worker (BSW) was overseen by the MSW for one of six sampled patients (Patient 4). (Refer to L594). 3. The HA failed to provide post death bereavement services to one of six sampled patients (Patient 3). (Refer to L596). 4. The HA failed to ensure four of six sampled patients (Patient 1, Patient 2, Patient 5 and Patient 6) receive initial spiritual counseling assessments to meet their spiritual needs. (Refer to L598). These deficient practices resulted in the HA not providing the core services/care as required and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life.

Based on interview and record review, the Hospice Agency (HA) failed to ensure two of six sampled patients (Patient 1 and Patient 2) had their terminal illness managed and overseen by a physician. This failure resulted in patients not being seen or cared for by a physician. --- , a. A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. It also indicated the Medical Doctor 2 (MD2) was assigned as her Medical Director and Referring/Attending/Patients Choice. b. A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including chronic obstructive pulmonary disease (COPD-constriction of the airways and difficulty or discomfort in breathing). It also indicated the Medical Doctor 2 (MD2) was assigned as his Medical Director and Referring/Attending/Patients Choice. During a telephone interview on 6/29/2023 at 2:28 p.m. with the Medical Doctor 2 (MD2), MD2 stated that he has not certified any patients for hospice care since December 2022. MD2 also stated, ";No, they did not call me to certify any patient they just called me for approval from the pharmacy." MD2 was asked about P2. MD2 stated, ";I dont recall him, I was probably not called regarding him." MD2 was asked about P1. MD2 stated, ";She doesnt sound familiar, I have not certified her for hospice benefits." During an interview on 6/30/2023 at 2:12 p.m. with the Administrator (ADM), the ADM stated MD2 has been an employee since April 2022 and that he has not been to the office. ADM also stated that she has been using his username and password to log into the facilitys Electronic Medical Record (EMR) with his permission. ADM stated, ";He gave me permission to enter the verbal report that he gave me and to sign on behalf of him." A review of facilitys public brochure, undated, indicated ";Care is provided by an Interdisciplinary Team of Hospice-trained professional including Physician... Clinical Social Worker, non-denominational chaplains..." A review of facilitys policy and procedure titled, ";Admission Criteria and Process" dated May 2023, indicated ";The patients life-limiting illness and prognosis of six (6) months of less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCD). 1. The agency will admit a patient only on recommendation of the medical director in consultation with, or input from the patients attending physician... 3. The patient must have a life-limiting illness with a life expectancy of six (6) moths or less, as determined by the attending physician... utilizing standard clinical prognosis criteria in the organizations intermediary Local coverage Determination. 4. The patient must desire hospice services and be aware of the diagnosis and prognosis." A review of facilitys policy and procedure titled, ";Entries into the Clinical Record" dated May 2023, indicated ";Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. 1. A clinical record... will include at a minimum: C. Physician (or other license practitioner) orders and evidence of physician oversight activities." A review of facilitys policy and procedure titled, ";Initial Assessment" dated May 2023, indicated ";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."

Based on interview and record review, the Hospice Agency (HA) failed to provide post death bereavement services to one of six sampled patients (Patient 3). This failure resulted in Patient 3s family and/or caregiver to not receive the emotional, psychological, and spiritual support after Patient 3s death. --- , A record review of Patient 3s (P3) ";Personal Information", indicated P3 had a Start of Care (SOC) date of 8/8/2022 and End of Care (EOC) date of 12/24/2022, with a primary diagnoses including hypertensive (high blood pressure) heart disease with heart failure. During a concurrent interview and record review on 6/29/2023 at 1 p.m. with the Administrator (ADM) of P3s Electronic Medical Record (EMR), the EMR indicted there was no post death bereavement assessment documented. ADM stated that P3s post bereavement assessment was not completed. ADM stated that the post death bereavement assessment is needed, ";so the family gets the support needed after the patient passes." ADM also stated that the social worker was not made aware when P3 passed away. Lastly, the ADM stated, ";the hospice responsibility was to provide the bereavement upon admission and at the time of death. We usually like to send a card in a year. There has not been anything sent to the family, not at the moment, it has not been a year yet." A review of facilitys public brochure, undated, indicated ";Care is provided by an Interdisciplinary Team of Hospice-trained professional including Physician... Clinical Social Worker, non-denominational chaplains..." A review of facilitys policy and procedure titled, ";Bereavement Services" dated May 2023, indicated ";5. After a death has occurred, the bereavement assessment will be updated...8. Within two (2) weeks after the death pf a patient, a sympathy card will be sent to the bereaved. 9. After three (3) to five (5) weeks after the patients death, a bereavement assessment will be completed by the bereavement counselor following the family/caregiver. 11. If a person is noted as experiencing normal grief, the bereavement counselor will contact the bereaved person for ongoing assessment and support at three (3), six (6), and nine (9) months after the patients death and the anniversary of the patients death." A review of facilitys policy and procedure titled, ";Initial Assessment" dated May 2023, indicated ";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."

Based on interview and record review, the Hospice Agency (HA) failed to ensure four of six sampled patients (Patient 1, Patient 2, Patient 5, and Patient 6) received a spiritual counseling assessment to meet their spiritual needs. This failure had the potential to place patients at risk of not receiving the care in accordance with their spiritual beliefs and desires. --- , a. A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. A review of P1s medical record form titled, ";Comprehensive Nursing Assessment" dated 3/11/2023, indicated ";MSW (Medical Social Worker) will call the patient and family within 5 days to render initial assessment. SC (Spiritual Counselor) will call the patient and family within 5 days to render initial assessment." Under the ";Narrative & Disease Trajectory" indicated ";It was determined that she would benefit from Psycho-social counseling and Spiritual support as part of Hospice care services." A review of P1s medical record form titled, ";Spiritual Assessment" dated 3/14/2023, indicated in the ";Narrative" section ";SC (Spiritual Counseling) evaluation/services declined at this time. SC will remain available as needed or requested." The form also indicated it was signed by the Administrator (ADM). During a concurrent interview and record review on 6/29/2023 at 10:50 a.m. p.m. with the ADM, of P1s Electronic Medical Record (EMR), the ADM stated that the initial SC should be completed within five days of admission by the facilitys Chaplain. ADM stated, ";He is part of the IDG (Interdisciplinary Group) team, his duties are to provide emotional support to the patient and family." ADM also stated, ";If they refuse, we tell them that the social worker and chaplain will call them to explain the services offered." ADM also stated that if they receive spiritual services, ";They are not going to benefit from the Chaplains help, they are not going to get the emotional support that they need, religious matters." b. A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including chronic obstructive pulmonary disease (COPD-constriction of the airways and difficulty or discomfort in breathing). A review of P2s medical record form titled, ";Comprehensive Nursing Assessment" dated 3/11/2023, indicated ";MSW (Medical Social Worker) will call the patient and family within 5 days to render initial assessment. SC (Spiritual Counselor will call the patient and family within 5 days to render initial assessment." Under the ";Narrative & Disease Trajectory" indicated ";Based on his initial assessment, it was determined that he would benefit from Psycho-social counseling and Spiritual support as part of Hospice care services." A review of P2s medical record form titled, ";Spiritual Assessment" dated 3/14/2023, indicated in the ";Narrative" section ";SC (Spiritual Counseling) evaluation/services declined at this time. SC will remain available as needed or requested." The form also indicated it was signed by the Administrator (ADM). During a concurrent interview and record review on 6/29/2023 at 12:30 p.m. with the ADM, of P2s EMR, the EMR indicated the initial spiritual assessment was not documented. ADM stated, ";He refused when I did my initial assessment. There is no documentation the social worker reached out to him. There should be a note by the social worker, that would be the proof that it was done." During an interview on 6/28/2023 at 11:50 a.m. with the ADM, the ADM stated, ";We offer them a social worker and a chaplain. We let them know that the social worker and chaplain are available, and they will call them to make an appointment to see them. I expect the social worker and chaplain to call and let them know they are available. They explain their services. They are more able to, I only emphasize to the patients that they are available..." During an interview on 6/29/2023 at 10:50 a.m. with the Administrator (ADM), the ADM stated, ";On admission I just let the patient know that the social worker and spiritual counselor are available." ADM stated that office personnel inform the social worker about a new patient, they are assigned, and they are responsible for calling the patient and or family. They call the social worker and Chaplin with every new admission. Once the social worker and chaplain know about a new admission, they need to contact the patient within five days of admission." During a telephone interview on 6/28/2023 at 12:23 p.m. with the Chaplain/Spiritual Counselor (SC), SC stated, ";When they need me, they send me an email. I receive the email with the patients that have been assigned to me for spiritual support. I usually call them; I provide my services mainly over the phone." c. A record review of Patient 5s (P5) ";Personal Information", indicated P5 had a Start of Care (SOC) date of 3/20/2023 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). During a concurrent interview and record review on 6/30/23, at 11:24 a.m. P5s record titled, ";POC/IDG review", dated 3/20/23, was reviewed with the administrator ADM. The record indicated, ";IDG Discussion...Spiritual:-SC (spiritual counselor) was informed of patient admission and will be calling the Patient/Family to schedule an appointment for an initial SC visit. Spiritual Care Coordinator for Spiritual Assessment within 5 days of Admission to Identify Spiritual Needs/Support to Patient, Family, and Primary Caregiver." The ADM stated the SC did not call the patient. The ADM stated P5s spiritual needs were not assessed because the SC needed to have done that. The ADM stated the effect of not having an SC assessment would mean P5 would not be able to benefit from the program, emotional needs might not be met. d.A record review of Patient 6s (P6) ";Personal Information", indicated P6 had a Start of Care (SOC) date of 1/30/2023 and an End of Care (EOC) date of 2/16/2023, with a primary diagnoses including heart failure (when the heart doesnt pump enough blood for the bodys needs). During a concurrent interview and record review on 6/30/23, at 10:40 a.m. P6s record titled, ";POC/IDG review", dated 1/30/23, was reviewed with the ADM. The record indicated, ";IDG Discussion...Spiritual:-SC (spiritual counselor) was informed of patient admission and will be calling the Patient/Family to schedule an appointment for an initial SC visit. Spiritual Care Coordinator for Spiritual Assessment within 5 days of Admission to Identify Spiritual Needs/Support to Patient, Family, and Primary Caregiver." Further review of the record indicated, on 1/30/23, the SC signed the document. The ADM stated the SC should have been the one calling the patient because he is the best one to explain what SC services are and what benefits the patient can have from the service. The ADM stated there was no note to indicate a call was made to the patient. The ADM stated the effect of not having an SC assessment was the Patient and or family will not be able to receive spiritual care and spiritual needs are not met. During a concurrent interview and record review on 6/30/23, at 10:42 a.m., P6s record titled, ";Spiritual Assessment", dated 2/1/23, was reviewed with the ADM. The record indicated, ";...6. Care Provided & Narrative...-SC evaluation/services declined at this time. SC will remain available as needed or requested." Further review of the record indicated the ADM signed the document. The ADM stated she had composed the note. The ADM stated it was hard to recall what happened. The note doesnt say what was explained to the patient and the reason the patient declined. The note doesnt tell the story. The ADM stated the chaplain, or the person who actually provided the service should be documenting the note. A review of facilitys public brochure, undated, indicated ";Care is provided by an Interdisciplinary Team of Hospice-trained professional including Physician... Clinical Social Worker, non-denominational chaplains..." A review of facilitys policy and procedure titled, ";Spiritual Assessment" dated May 2023, indicated ";An in-depth spiritual assessment will be completed for each patient/family by the Hospice Chaplain. 4. The in-depth spiritual assessment will be performed by the Hospice Chaplain: A. in the patients residence B. In the hospital if the patient is hospitalized... 7. After the spiritual assessment is performed, ongoing contact will be maintained by phone and/or home visits by the Hospice Chaplain...1. On admission, the hospice registered nurse will conduct an initial spiritual assessment. 5. The spiritual assessment will include, but not be limited to: A. patients spiritual response to the terminal illness and treatment interventions B. survivor risk factors, such as availability of coping mechanisms and the potential for pathological grief reactions C. Available religious spiritual support D. Coping styles and impact of illness or spirituality E. Anticipatory grief assessment." A review of facilitys policy and procedure titled, ";Initial Assessment" dated May 2023, indicated ";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."

Based on interview and record review the Hospice Agency (HA) failed to conduct a Certified Home Health Aide (CHHA) supervisory visit every 14 days one of six sampled patients (Patient 3). This failure had the potential to result in patients being taken care of by an unqualified CHHA. --- , A record review of Patient 3s (P3) ";Personal Information", indicated P3 had a Start of Care (SOC) date of 8/8/2022 and End of Care (EOC) date of 12/24/2022, with a primary diagnoses including hypertensive (high blood pressure) heart disease with heart failure. A review of P3s medical record form titled ";Comprehensive Nursing Assessment" dated 8/8/2022, indicated ";Need for Hospice Aide – grooming – linen change...; CHHA (Certified Home Health Aide) services: 2x/week." A review of P3s medical record form titled ";POC Summary" dated 12/22/2022, indicated ";SN (Skilled Nurse) 1 per week + 1 PRN (as needed) visits..." During a concurrent interview and record review on 6/29/2023 at 1 p.m. with the ADM, of P3s EMR, the EMR indicated there were two CHHA supervisory visits made on 9/5/2022 and 9/19/2022. ADM stated that CHHA supervisory visits should be done every other week, in order to supervise the care being provided to the patient. ADM also stated that if the CHHA supervisory visits are not done the patients needs might not be met. During an interview on 6/29/2023 at 10:50 a.m. with the Administrator (ADM), the ADM stated, ";Within 24 hours of the visit notes are supposed to be documented. They are to be in (EMR) within the 24 hours." ADM also stated that it was important to document visit notes, ";to be on time, the moment that you do the visit you document. To be on time." A review of facilitys policy and procedure titled, ";Responsibilities/Supervision of Clinical Services" dated May 2023, indicated ";Supervision of clinical care and services will be available 24 hours a day, seven (7) days a week. The Clinical Director will monitor the care and services provided by hospice personnel and contract personnel. Hospice aide supervisory visits will be conducted on-site at least every 14 days by a hospice registered nurse. LPN/LVN will be supervised by a registered nurse as directed by the State Practice Act, whichever is more frequent. Social worker (baccalaureate prepared) supervision will be completed by a masters prepared medical social worker at least every 30 days. A review of facilitys policy and procedure titled, ";Missed Visits" dated May 2023, indicated ";If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week... If a visit is missed and not rescheduled the clinician will: B. Document in the patients clinical record the following information: 2. Date and type of visit that was missed 3. Reason for the missed visit 6. Other person(s) that were notified of the missed visit... If an aide visit is missed the aide will contact the case manager or clinical supervisor..." A review of facilitys policy and procedure titled, ";The Plan of Care" dated May 2023, indicated ";The Plan of Care will identify the patients needs and services to meet those needs... 8. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments... 14. Care provided to the patient will be in accordance with the plan of care." A review of facilitys policy and procedure titled, ";Entries into the Clinical Record" dated May 2023, indicated ";Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. 1. A clinical record... will include at a minimum: J. Reason for interruption in the provision of care and services. 6. Entries into the clinical record will be made on the date care is provided to the patient. All documentation will be turned in to the office within seven (7) days." A review of facilitys policy and procedure titled, ";Clinical Data Collection Review" undated, indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services."

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 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 for four of six sample patients (Patient1, Patient 2, Patient 4 and Patient 6) 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 the patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice are and services. (Refer to L 667). 2. The hospice agency 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 four of six sample patients (Patient1, Patient 2, Patient 4, and Patient 6). (Refer to L 668). 3. The hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospice patient care program, that included, conducting an assessment, review, and verifying patient clinical information to consistently meet the needs of two of six sampled patients (Patient 1 and Patient 2). (Refer to L 669). 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 the highest quality of patient care are provided to the patients certified to receive hospice services. --- , 1. The hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications for four of six sample patients (Patient1, Patient 2, Patient 4 and Patient 6) 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 are and services. (Refer to L 667). 2. The hospice agency failed to ensure medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for four of six sample patients (Patient1, Patient 2, Patient 4, and Patient 6). (Refer to L 668). 3. The hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospices patient care program, that included, conducting an assessment, review, and verify patient clinical information to consistently meet the needs for two of six sampled patients (Patient 1 and Patient 2). (Refer to L 669). 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 failed to ensure, the medical director and/or physician designee conducted an accurate assessment, reviewed, and verified the patient clinical information, necessary for initial certifications for four of six sample patients (Patient 1, Patient 2, Patient 4, and Patient 6) to support the 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 the patients history and physicals, laboratory and imaging data, biopsy results, etc., necessary for initial certification of hospice are and services. These deficient practices resulted in the hospice medical director and/or the hospice attending physicians to certify patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses and could result inappropriate care provided to the patients. --- . a. A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. It also indicated the Medical Doctor 2 (MD2) was assigned as her Medical Director and Referring/Attending/Patients Choice. A review of P1s medical record form titled, ";Physician Certification for Hospice Benefit" dated 3/11/2023 to 6/8/2023, indicated ";Total number of activities with complete dependence 4 of 6 activities: ambulation, transfer, toileting, bathing. KPS 50 (Karnofsky Performance Status – measure the level of patient activity – 50%: requires considerable assistance and frequent medical care), PPS 50 (Palliative Performance Scale - tool to assess a patients ability to function – 40%: mainly in bed, unable to do most activities). NYHA IV (New York Heart Association Class IV – inability to carry on any physical activity without discomfort, experiences symptoms even while at rest)." It also indicated MD2 electronically signed the form. During a joint home visit on 6/28/2023 at 10:30 a.m. with the Administrator (ADM) to P1s home, ADM stated that P1s sister is their caregiver and stated, ";She comes here often if they need something, she lives around here, right around the corner." P1 answered the door and invited us in. P1 then ambulated without a cane or walker to the dining room and sat on a dining room chair. P1 stated that she just had some coffee and will be deciding on what to make herself and her husband for breakfast. P1 also stated that she took her high blood pressure medication about an hour ago. ADM stated to P1, ";I know you know your name, the date, where youre at. Im going to take your vitals. Did you take your morning medications?" ADM started taking P1s vital signs. During an interview on 6/28/2023 at 12:51 p.m. with P1, P1 was asked what hospice services were. P1 stated, ";They help people that cant, disable people that are unable to pick up their medication. They bring the medication to you. They are very helpful. I didnt have a way to get my medicine." P1 also stated that she was never told that she had six months or less to live. P1 stated, ";I wasnt told that. Thats new to me. No, there has not been a doctor that told me I had six months or less to live. I havent seen the agencys doctor either. I hope he does not come tell me Im going to die soon. I had to go to the urgent care sometime last week because I injured my finger. I called the nurse the next day and told her about it. I guess I was not allowed to do that. (P2) has not been told either." During a concurrent interview and record review on 6/29/2023 at 11:50 a.m. with the Administrator (ADM) or P1s Electronic Medical Record (EMR), the ADM stated that P1s terminal illness diagnoses were Hypertension (HTN – high blood pressure), angina (chest pain cause by inadequate blood supply to the heart) and shortness of breath. ADM stated, ";The doctor came out with the diagnoses because of her symptoms." ADM also stated that she documented and used the LCD. The EMR indicated that P1 had NYHA Class IV, had an ejection fraction of <20 (the heart is not pumping all the oxygen rich blood the body needs), KPS 50%, and PPS 40%. ADM stated, ";She is not a CHF patient, but she has angina and takes nitro. The heart, the way her heart works its low." ADM stated that P1 met hospice criteria, ";because patient has heart disease. The tele visit was done with the doctor and we discuss about that. The doctor made that diagnosis. These are objective findings; we never got an H&P (History and physical). I have none." ADM stated that she assigned P1 a KPS score of 50% due to, ";I put 50 because that is what I thought that she needs assistance with. She does require a lot of assistance and frequent medical care." PPS score of 40% was determined by the ADM due to, ";she is mainly in bed, unable to do any work, she is dependence for care." ADM stated that P1 met hospice criteria. b. A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including chronic obstructive pulmonary disease (COPD-constriction of the airways and difficulty or discomfort in breathing). It also indicated the Medical Doctor 2 (MD2) was assigned as his Medical Director and Referring/Attending/Patients Choice. A review of P2s medical record form titled, ";Physician Certification for Hospice Benefit" dated 3/11/2023 to 6/8/2023, indicated ";Total number of activities with complete dependence 4 of 6 activities: ambulation, transfer, toileting, bathing. KPS 50 PPS 50." It also indicated MD2 electronically signed the form. A review of P2s medical record form titled, ";LCD Hospice Eligibility Determination" (Local Coverage Determination – guidelines used to determine if the patient is hospice appropriate) dated 3/11/2023, indicated ";Patient is eligible per LCD guidelines – Pulmonary Disease: 1 and 2 must be met. 2. Increased visits to ER? Yes, Hospitalization for pulmonary infections? Yes." During a joint home visit on 6/28/2023 at 10:30 a.m. with the Administrator (ADM) to P2s home, ADM stated that P2s sister-in-law is his caregiver and stated, ";She comes here often if they need something, she lives around here, right around the corner." P2 was noted sitting on single reclining sofa dressed watching television with a nasal canula in nose, receiving oxygen. P2 complained of right lower abdominal pain, ADM assisted P2 pull pants down and assessed pain and skin integrity. During an interview on 6/28/2023 at 12:51 p.m. with P2, P2 stated, ";Im sick but no one told me I will die in six months." During a concurrent interview and record review on 6/30/2023 at 2:05 p.m. with the Administrator (ADM) or P2s Electronic Medical Record (EMR), the ADM stated that she filled out P2s LCD but was unable to recall where she received the information from. ADM stated that there is no documentation to support P2 had increased emergency room visits or that he has been hospitalized for respiratory infections. ADM stated, ";Seems like none of them apply, after discussing the LCD with you I realize that none of them apply. Now that we review this, patient does not qualify for hospice services." During a telephone interview on 6/29/2023 at 2:28 p.m. with the Medical Doctor 2 (MD2), MD2 stated that he has not certified any patients for hospice care since December 2022. MD2 also stated, ";No, they did not call me to certify any patient they just called me for approval from the pharmacy." MD2 was asked about P2. MD2 stated, ";I dont recall him, I was probably not called regarding him." MD2 was asked about P1. MD2 stated, ";She doesnt sound familiar, I have not certified her for hospice benefits." During an interview on 6/30/2023 at 2:12 p.m. with the Administrator (ADM), the ADM stated MD2 has been an employee since April 2022 and that he has not been to the office. ADM also stated that she has been using his username and password to log into the facilitys Electronic Medical Record (EMR) with his permission. ADM stated, ";He gave me permission to enter the verbal report that he gave me and to sign on behalf of him." c. A record review of Patient 4s (P4) ";Personal Information", indicated P4 had a Start of Care (SOC) date of 2/9/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. During an interview during the home visit on 6/28/23, at 11:15 a.m., P4 stated she did not have heart problems and her health status was under control. During an interview during the home visit on 6/28/23, at 11:50 a.m., P4 stated she did not know what hospice care was. P4 stated she did not have a terminal illness and a doctor had not told her she had 6 months or less to live. During an interview on 6/29/23, at 2:45 p.m., Medical Doctor 1 (MD 1) stated he was the medical director for the HA, whose duties included supervision of the operations of the HA, review of medical records to make sure the patients are qualified for hospice services. MD 1 stated certifying the patients for hospice care included looking at the diagnosis, to make sure patient has a terminal illness, and the patients physical function is declining. The process also included interviewing the patient, and reviewing medical records provided by the HA. MD 1 stated the first visit involves a telehealth (a visit done by phone or video) visit with the nurse who is in person at the patients residence. During an interview on 6/29/23, at 2:45 p.m., MD 1 stated he documented his assessment findings in a paper document that is sent to the HA. MD 1 stated he did not compose the narrative in the electronic medical record (EMR), and the HA incorporated his paper document into the physician narrative in the EMR. During a concurrent interview and record review on 6/29/23, at 3:10 p.m., P4s record titled, ";Physicians Certification for Hospice Benefit (CTI)", for certification 2/9/23 to 5/9/23, was reviewed with MD 1. The record indicated, ";Physician Narrative...with terminal diagnosis of hypertensive heart disease without heart failure...patients health is slowly deteriorating due to his/her diagnosis...Medical Director Attestation/Certification I attends/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Further review of the record indicated MD 1 signed the document on 2/9/23. MD 1 stated he had written the narrative. MD 1 stated the document did not have enough medical information to certify the patient for hospice care. MD 1 stated he did not think he wrote the narrative. MD 1 stated his signature indicated he had written the narrative. MD 1 stated he had included medical information in his paper narrative and the HA staff didnt put the information in the P4s medical record, specifically the CTI. During an interview on 6/29/23 at 3:19 p.m., MD 1 stated it was important for the CTI to have objective medical information because it should show exactly how the patient is doing. That they are really declining and justifying on why the patient needs to be in the program. d. A record review of Patient 6s (P6) ";Personal Information", indicated P6 had a Start of Care (SOC) date of 1/30/2023 and an End of Care (EOC) date of 2/16/2023, with a primary diagnoses including heart failure (when the heart doesnt pump enough blood for the bodys needs). During a concurrent interview and record review on 6/29/23, at 2:57 p.m. P6s record titled, ";Physicians Certification for Hospice Benefit (CTI)", for certification 1/30/23 to 4/29/23, was reviewed with MD 1. MD 1 stated he had composed the note, as validated by his signature. MD 1 stated he had reviewed medical records, along with the nurse and determined P6 had end stage heart failure. During an interview on 6/30/23, at 10:45 a.m., the administrator (ADM) stated there was no History and Physical (H&P, a document written by a doctor describing the health history, the current health conditions, and the plan for care) or any other medical documents to support the diagnosis of heart failure. The ADM stated it was important to have medical documents because it can assist the doctor in having a bigger picture about the patients condition. Medical documents help in determining if patient has hospice criteria. During a concurrent interview and record review on 6/30/23, at 10:45 a.m., P6s record titled, ";LCD Hospice Eligibility Determination", dated 1/30/23, was reviewed with the ADM. The record indicated, ";Heart Disease...2. NYHA classification (condition a must be met) 2a. Does this CHF or angina by patient meet the criteria for NYHA Class IV level? Yes. 2b. Is Ejection fraction <20 (if available) Yes.". The ADM stated ";yes" was answered for question 2a because P6 would become very fatigued when walking and would require frequent rest periods. The ADM stated she could not recall where she got the information to answer ";yes" for question 2b. The ADM stated P6s admission was inaccurate. The ADM stated the effect of admitting P5 to hospice care, without a terminal illness, was that he would have limited services in the community. A review of facilitys policy and procedure titled, ";Responsibilities/Supervision of Clinical Services" dated May 2023, indicated ";Supervision of clinical care and services will be available 24 hours a day, seven (7) days a week. The Clinical Director will oversee the day-to-day clinical operations. The Clinical Director will monitor the care and services provided by hospice personnel and contract personnel." A review of facilitys policy and procedure titled, ";Certification of Terminal Illness" dated May 2023, indicated ";When certifying the patient as terminally ill, the hospice medical director...or physician designee must consider at least the diagnosis of the terminal condition of the patient, other health related conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. At the time of admission to hospice, the hospice Medical Director... or the patients attending physician will complete a certification narrative that reflect the patients individual circumstances based on: his/her review of the patients medical record... 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. Tools such as the fiscal intermediarys Local Coverage Determination, along with other supporting documentation, can be used to provide guidance in determining and documenting terminal prognosis." A review of facilitys policy and procedure titled, ";LCD – Hospice – Determining Terminal Status" undated, indicated ";Heart Disease – patients will be considered to be in the terminal stage of heart disease if they meet the following criteria. 1 and 2 should be present. 1. At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease... 2. Patients with congestive heart failure or angina shole meet the New York Heart Association (NYHA) Class IV. Class IV patients will heat disease have an inability to carry on any physical activity. Symptoms of heat failure of the anginal syndrome may be present even at rest. Pulmonary Disease - patients will be considered to be in the terminal stage of pulmonary disease if they meet the following criteria... 1 and 2 should be present. 1. Severe chronic lung disease as documented by both a and b. a. disabling dyspnea at rest...b. progression of end stage pulmonary disease, as evidence by increasing visits to the emergency department or hospitalization for pulmonary infections and/or respiratory failure. 2. Hypoxemia at rest on room air, as evidence by p02 less than or equal to 55 mmHg, or oxygen saturation less than or equal to 88%, determined either by arterial blood gases or oxygen saturation monitors." A review of facilitys policy and procedure titled, ";The Plan of Care" dated May 2023, indicated ";6. The hospice Medical Director will need to review the patients history and physical, which is also provided, to be able to sign the certification of terminal illness section of the plan of care. 8. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments..." A review of facilitys policy and procedure titled, ";Admission Criteria and Process" dated May 2023, indicated ";The patients life-limiting illness and prognosis of six (6) months of less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCD). 1. The agency will admit a patient only on recommendation of the medical director in consultation with, or input from the patients attending physician... 3. The patient must have a life-limiting illness with a life expectancy of six (6) moths or less, as determined by the attending physician... utilizing standard clinical prognosis criteria in the organizations intermediary Local coverage Determination. 4. The patient must desire hospice services and be aware of the diagnosis and prognosis." A review of facilitys policy and procedure titled, ";Entries into the Clinical Record" dated May 2023, indicated ";Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. 1. A clinical record... will include at a minimum: C. Physician (or other license practitioner) orders and evidence of physician oversight activities."

Based on interview and record review the Hospice Agency (HA) failed to ensure the medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for four of six sample patients (Patient 1, Patient 2, Patient 4, and Patient 5). This deficient practice 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. A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. It also indicated the Medical Doctor 2 (MD2) was assigned as her Medical Director and Referring/Attending/Patients Choice. A review of P1s medical record form titled, ";Physician Certification for Hospice Benefit" dated 6/9/2023 to 9/6/2023, indicated ";Total number of activities with complete dependence 4 of 6 activities: ambulation, transfer, toileting, bathing. KPS 50 (Karnofsky Performance Status – measure the level of patient activity – 50%: requires considerable assistance and frequent medical care), PPS 50 (Palliative Performance Scale - tool to assess a patients ability to function – 40%: mainly in bed, unable to do most activities). NYHA IV (New York Heart Association Class IV – inability to carry on any physical activity without discomfort, experiences symptoms even while at rest)." It also indicated MD2 electronically signed the form. During a joint home visit on 6/28/2023 at 10:30 a.m. with the Administrator (ADM) to P1s home, ADM stated that P1s sister is their caregiver and stated, ";She comes here often if they need something, she lives around here, right around the corner." P1 answered the door and invited us in. P1 then ambulated without a cane or walker to the dining room and sat on a dining room chair. P1 stated that she just had some coffee and will be deciding on what to make herself and her husband for breakfast. P1 also stated that she took her high blood pressure medication about an hour ago. ADM stated to P1, ";I know you know your name, the date, where youre at. Im going to take your vitals. Did you take your morning medications?" ADM started taking P1s vital signs. During an interview on 6/28/2023 at 12:51 p.m. with P1, P1 was asked what hospice services were. P1 stated, ";They help people that cant, disable people that are unable to pick up their medication. They bring the medication to you. They are very helpful. I didnt have a way to get my medicine." P1 also stated that she was never told that she had six months or less to live. P1 stated, ";I wasnt told that. Thats new to me. No, there has not been a doctor that told me I had six months or less to live. I havent seen the agencys doctor either. I hope he does not come tell me Im going to die soon. I had to go to the urgent care sometime last week because I injured my finger. I called the nurse the next day and told her about it. I guess I was not allowed to do that. (P2) has not been told either." During a concurrent interview and record review on 6/29/2023 at 11:50 a.m. with the Administrator (ADM) or P1s Electronic Medical Record (EMR), the ADM stated that P1s terminal illness diagnoses were Hypertension (HTN – high blood pressure), angina (chest pain cause by inadequate blood supply to the heart) and shortness of breath. ADM stated, ";The doctor came out with the diagnoses because of her symptoms." ADM also stated that she documented and used the LCD. The EMR indicated that P1 had NYHA Class IV, had an ejection fraction of <20 (the heart is not pumping all the oxygen rich blood the body needs), KPS 50%, and PPS 40%. ADM stated, ";She is not a CHF patient, but she has angina and takes nitro. The heart, the way her heart works its low." ADM stated that P1 met hospice criteria, ";because patient has heart disease. The tele visit was done with the doctor and we discuss about that. The doctor made that diagnosis. These are objective findings; we never got an H&P (History and physical). I have none." ADM stated that she assigned P1 a KPS score of 50% due to, ";I put 50 because that is what I thought that she needs assistance with. She does require a lot of assistance and frequent medical care." PPS score of 40% was determined by the ADM due to, ";she is mainly in bed, unable to do any work, she is dependence for care." ADM stated that P1 met hospice criteria. b. A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including chronic obstructive pulmonary disease (COPD-constriction of the airways and difficulty or discomfort in breathing). It also indicated the Medical Doctor 2 (MD2) was assigned as his Medical Director and Referring/Attending/Patients Choice. A review of P2s medical record form titled, ";Physician Certification for Hospice Benefit" dated 6/9/2023 to 9/6/2023, indicated ";Total number of activities with complete dependence 4 of 6 activities: ambulation, transfer, toileting, bathing. KPS 50, PPS 50." It also indicated MD2 electronically signed the form. A review of P2s medical record form titled, ";LCD Hospice Eligibility Determination" (Local Coverage Determination – guidelines used to determine if the patient is hospice appropriate) dated 6/2/2023, indicated ";Patient is eligible per LCD guidelines – Pulmonary Disease: 1 and 2 must be met. 2. Increased visits to ER? Yes, Hospitalization for pulmonary infections? Yes." During a joint home visit on 6/28/2023 at 10:30 a.m. with the Administrator (ADM) to P2s home, ADM stated that P2s sister-in-law is his caregiver and stated, ";She comes here often if they need something, she lives around here, right around the corner." P2 was noted sitting on single reclining sofa dressed watching television with a nasal canula in nose, receiving oxygen. P2 complained of right lower abdominal pain, ADM assisted P2 pull pants down and assessed pain and skin integrity. During an interview on 6/28/2023 at 12:51 p.m. with P2, P2 stated, ";Im sick but no one told me I will die in six months." During a concurrent interview and record review on 6/30/2023 at 2:05 p.m. with the Administrator (ADM) or P2s Electronic Medical Record (EMR), the ADM stated that she filled out P2s LCD but was unable to recall where she received the information from. ADM stated that there is no documentation to support P2 had increased emergency room visits or that he has been hospitalized for respiratory infections. ADM stated, ";Seems like none of them apply, after discussing the LCD with you I realize that none of them apply. Now that we review this, patient does not qualify for hospice services." During a telephone interview on 6/29/2023 at 2:28 p.m. with the Medical Doctor 2 (MD2), MD2 stated that he has not certified any patients for hospice care since December 2022. MD2 also stated, ";No, they did not call me to certify any patient they just called me for approval from the pharmacy." MD2 was asked about P2. MD2 stated, ";I dont recall him, I was probably not called regarding him." MD2 was asked about P1. MD2 stated, ";She doesnt sound familiar, I have not certified her for hospice benefits." During an interview on 6/30/2023 at 2:12 p.m. with the Administrator (ADM), the ADM stated MD2 has been an employee since April 2022 and that he has not been to the office. ADM also stated that she has been using his username and password to log into the facilitys Electronic Medical Record (EMR) with his permission. ADM stated, ";He gave me permission to enter the verbal report that he gave me and to sign on behalf of him." c. A record review of Patient 4s (P4) ";Personal Information", indicated P4 had a Start of Care (SOC) date of 2/9/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. During a concurrent observation and interview, during a home visit, on 6/28/23, at 10:41 a.m., P4 stated she does exercises at home to help with her hip. P4 was observed getting up from the living room chair, walked across the living area, without an assistive device, to get a blue ball. P4 was observed voluntarily demonstrating her exercise routine to the RN and the representative of the California Department of Public Health. P4 stated she also does exercises for her arms. During the demonstration of P4s exercise routine, P4 was breathing normally, and no discomfort was reported. During a concurrent observation and interview, during a home visit on 6/28/23, at 10:45 a.m., RN was observed interviewing P4. RN asked P4 how many steps she takes before needing rest. P4 stated to the RN she did not know how many steps she takes because she walks as much as possible. P4 stated she uses a walker to walk to the market, outside, and to doctors appointments. During a concurrent observation and interview on 6/28/23, at 11:13 a.m., RN was observed interviewing P4. RN 4 was observed instructing P4 on medication use for chest pain. P4 stated to RN that she has not had to use the medication because she had never experienced chest pain. During an interview during the home visit on 6/28/23, at 11:15 a.m., P4 stated she did not have heart problems and her health status was under control. During an interview during the home visit on 6/28/23, at 11:50 a.m., P4 stated she did not know what hospice care was. P4 stated she did not have a terminal illness and a doctor had not told her she had 6 months or less to live. During an interview on 6/29/23, at 2:45 p.m., Medical Doctor 1 (MD 1) stated he was the medical director for the HA, whose duties included review of medical records to make sure the patients are qualified for hospice services. MD 1 stated certifying the patients for hospice care included looking at the diagnosis, to make sure patient has a terminal illness, and the patients physical function is declining. The process also included interviewing the patient, and reviewing medical records provided by the HA. MD 1 stated the first visit involves a telehealth (a visit done by phone or video) visit with the nurse who is in person at the patients residence. During an interview on 6/29/23, at 2:45 p.m., MD 1 stated he documented his assessment findings in a paper document that is sent to the HA. MD 1 stated he does not compose the narrative in the electronic medical record (EMR), and the HA incorporates his paper document into the physician narrative in the EMR. During a concurrent interview and record review on 6/29/23, at 3:19 p.m., P4s record titled, ";Physicians Certification for Hospice Benefit (CTI)", for certification 5/10/23 to 8/7/23, was reviewed with MD 1. The record indicated, ";Physician Narrative...recertified in hospice under routine level of care, with primary diagnose of hypertensive heart disease without heart failure...The patients health progressively deteriorated...Patient displays increased weakness and fatigue along with steady decline in functional and overall cognitive status. Medical Director Attestation/Certification I attends/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Further review of the record indicated MD 1 signed the document on 5/3/23. MD 1 stated he had not written the narrative but had reviewed it. MD 1 stated he signed the document. MD 1 stated the document did not have enough medical information to re-certify the patient for hospice care. During an interview on 6/29/23 at 3:19 p.m., MD 1 stated it was important for the CTI to have objective medical information because it should show exactly how the patient is doing. That they are really declining and justifying on why the patient needs to be in the program. d. A record review of Patient 5s (P5) ";Personal Information", indicated P5 had a Start of Care (SOC) date of 3/20/2023 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). During an interview on 6/28/23, at 3:10 p.m. P5s Caregiver (CG) stated P5 did not have a terminal illness and a doctor had not informed them P5 had 6 months or less to live. The CG stated P5 activities included accompanying her to the market. CG stated the agency had provided oxygen for P5 in case he needed it and was thankful P5 had not had a need for it. CG stated P5 has never used oxygen because he does not have shortness of breath. During a concurrent interview and record review on 6/30/23, at 12:11 p.m., P5s record titled, ";Re-Cert Assessment", dated 6/5/23, was reviewed with the ADM. The record indicated, ";LCD Hospice Eligibility Determination...Patient is eligible per LCD Guidelines...Heart Disease 1. Untreatable Condition: 1a. Has patient been ruled out as a candidate for surgical procedures? Yes. 1b. Has patient declined surgical procedures? Yes. 1c.Is patient optimally treated for heart disease with diuretics (medications that help remove water from the body) and vasodilators (medications helping lower blood pressure)? Yes.". The ADM stated she could not recall where she obtained the information to answer ";yes" to questions 1a and 1b because the HA did not have medical documents to support the criteria. The ADM stated question 1c. should not have been answered because P5 was not on any diuretic or vasodilator. During a concurrent interview and record review on 6/30/23, at 12:11 p.m., P5s record titled, ";Re-Cert Assessment", dated 6/5/23, was reviewed with the ADM. The record indicated, ";LCD Hospice Eligibility Determination...Heart Disease...2. NYHA classification (condition a must be met) 2a. Does this CHF or angina by patient meet the criteria for NYHA Class IV level? Yes. 2b. Is Ejection fraction <20 (if available) Yes.". The ADM stated P5 had oxygen to use as needed. When asked if P5 was using oxygen, the ADM stated she did not mention anything about oxygen use in the medical records. The ADM stated she could not recall where she got the information to answer ";yes" to question 2b. The ADM stated the information to answer 2b should be in the medical documents, the HA did not have. The ADM stated the LCD assessment was not accurate. When asked what the qualifying criteria for hospice care was for P5, the ADM stated it was heart disease, but the HA did not have medical documents to support it. The ADM stated P5s admission was inaccurate. The ADM stated the effect of admitting P5 to hospice care, without a terminal illness, was that he would have limited services in the community. A review of P5s record titled, ";Physicians Certification for Hospice Benefit", for certification period 6/18/23 to 9/15/23, indicated ";LCD Determination Status: Physician Narrative: Please see attached...Medical Director Attestation/Certification I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." The record indicated Medical Doctor 3 (MD 3) signed the document on 6/5/23. The attachment indicated a face-to-face examination was completed by MD 3 on 6/6/23. A review of facilitys policy and procedure titled, ";Responsibilities/Supervision of Clinical Services" dated May 2023, indicated ";Supervision of clinical care and services will be available 24 hours a day, seven (7) days a week. The Clinical Director will oversee the day-to-day clinical operations. The Clinical Director will monitor the care and services provided by hospice personnel and contract personnel." A review of facilitys policy and procedure titled, ";Certification of Terminal Illness" dated May 2023, indicated ";When certifying the patient as terminally ill, the hospice medical director...or physician designee must consider at least the diagnosis of the terminal condition of the patient, other health related conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. At the time of admission to hospice, the hospice Medical Director... or the patients attending physician will complete a certification narrative that reflect the patients individual circumstances based on: his/her review of the patients medical record... 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. Tools such as the fiscal intermediarys Local Coverage Determination, along with other supporting documentation, can be used to provide guidance in determining and documenting terminal prognosis." A review of facilitys policy and procedure titled, ";LCD – Hospice – Determining Terminal Status" undated, indicated ";Heart Disease – patients will be considered to be in the terminal stage of heart disease if they meet the following criteria. 1 and 2 should be present. 1. At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease... 2. Patients with congestive heart failure or angina shole meet the New York Heart Association (NYHA) Class IV. Class IV patients will heat disease have an inability to carry on any physical activity. Symptoms of heat failure of the anginal syndrome may be present even at rest. Pulmonary Disease - patients will be considered to be in the terminal stage of pulmonary disease if they meet the following criteria... 1 and 2 should be present. 1. Severe chronic lung disease as documented by both a and b. a. disabling dyspnea at rest...b. progression of end stage pulmonary disease, as evidence by increasing visits to the emergency department or hospitalization for pulmonary infections and/or respiratory failure. 2. Hypoxemia at rest on room air, as evidence by p02 less than or equal to 55 mmHg, or oxygen saturation less than or equal to 88%, determined either by arterial blood gases or oxygen saturation monitors." A review of facilitys policy and procedure titled, ";The Plan of Care" dated May 2023, indicated ";6. The hospice Medical Director will need to review the patients history and physical, which is also provided, to be able to sign the certification of terminal illness section of the plan of care. 8. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments..." A review of facilitys policy and procedure titled, ";Admission Criteria and Process" dated May 2023, indicated ";The patients life-limiting illness and prognosis of six (6) months of less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCD). 1. The agency will admit a patient only on recommendation of the medical director in consultation with, or input from the patients attending physician... 3. The patient must have a life-limiting illness with a life expectancy of six (6) moths or less, as determined by the attending physician... utilizing standard clinical prognosis criteria in the organizations intermediary Local coverage Determination. 4. The patient must desire hospice services and be aware of the diagnosis and prognosis." A review of facilitys policy and procedure titled, ";Entries into the Clinical Record" dated May 2023, indicated ";Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. 1. A clinical record... will include at a minimum: C. Physician (or other license practitioner) orders and evidence of physician oversight activities."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the medical director or physician designee assumed responsibility for the medical component of the hospice patient care program, that included, conducting an assessment, review, and verifying the patient clinical information to consistently meet the needs for two of six sampled patients (Patient 1, and Patient 2). This failure resulted in the hospice medical director and/or the hospice attending physicians to certify patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses and this could result in a lack of and inappropriate care being provided to the patients. --- . a. A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. It also indicated the Medical Doctor 2 (MD2) was assigned as her Medical Director and Referring/Attending/Patients Choice. A review of P1s medical record form titled, ";Physician Certification for Hospice Benefit" dated 6/9/2023 to 9/6/2023, indicated ";Total number of activities with complete dependence 4 of 6 activities: ambulation, transfer, toileting, bathing. KPS 50 (Karnofsky Performance Status – measure the level of patient activity – 50%: requires considerable assistance and frequent medical care), PPS 50 (Palliative Performance Scale - tool to assess a patients ability to function – 40%: mainly in bed, unable to do most activities). NYHA IV (New York Heart Association Class IV – inability to carry on any physical activity without discomfort, experiences symptoms even while at rest)." It also indicated MD2 electronically signed the form. During a joint home visit on 6/28/2023 at 10:30 a.m. with the Administrator (ADM) to P1s home, ADM stated that P1s sister is their caregiver and stated, ";She comes here often if they need something, she lives around here, right around the corner." P1 answered the door and invited us in. P1 then ambulated without a cane or walker to the dining room and sat on a dining room chair. P1 stated that she just had some coffee and will be deciding on what to make herself and her husband for breakfast. P1 also stated that she took her high blood pressure medication about an hour ago." During an interview on 6/28/2023 at 12:51 p.m. with P1, P1 was asked what hospice services were. P1 stated, ";They help people that cant, disable people that are unable to pick up their medication. They bring the medication to you. They are very helpful. I didnt have a way to get my medicine." P1 also stated that she was never told that she had six months or less to live. P1 stated, ";I wasnt told that. Thats new to me. No, there has not been a doctor that told me I had six months or less to live. I havent seen the agencys doctor either. I hope he does not come tell me Im going to die soon. I had to go to the urgent care sometime last week because I injured my finger. I called the nurse the next day and told her about it. I guess I was not allowed to do that. (P2) has not been told either." During a concurrent interview and record review on 6/29/2023 at 11:50 a.m. with the Administrator (ADM) or P1s Electronic Medical Record (EMR), the ADM stated that P1s terminal illness diagnoses were Hypertension (HTN – high blood pressure), angina (chest pain cause by inadequate blood supply to the heart) and shortness of breath. ADM stated, ";The doctor came out with the diagnoses because of her symptoms." ADM also stated that she documented and used the LCD. The EMR indicated that P1 had NYHA Class IV, had an ejection fraction of <20 (the heart is not pumping all the oxygen rich blood the body needs), KPS 50%, and PPS 40%. ADM stated, ";She is not a CHF patient, but she has angina and takes nitro. The heart, the way her heart works its low." ADM stated that P1 met hospice criteria, ";because patient has heart disease. The tele visit was done with the doctor and we discuss about that. The doctor made that diagnosis. These are objective findings; we never got an H&P (History and physical). I have none." ADM stated that she assigned P1 a KPS score of 50% due to, ";I put 50 because that is what I thought that she needs assistance with. She does require a lot of assistance and frequent medical care." PPS score of 40% was determined by the ADM due to, ";she is mainly in bed, unable to do any work, she is dependence for care." ADM stated that P1 met hospice criteria. b. A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including chronic obstructive pulmonary disease (COPD-constriction of the airways and difficulty or discomfort in breathing). It also indicated the Medical Doctor 2 (MD2) was assigned as his Medical Director and Referring/Attending/Patients Choice. A review of P2s medical record form titled, ";Physician Certification for Hospice Benefit" dated 6/9/2023 to 9/6/2023, indicated ";Total number of activities with complete dependence 4 of 6 activities: ambulation, transfer, toileting, bathing. KPS 50, PPS 50." It also indicated MD2 electronically signed the form. A review of P2s medical record form titled, ";LCD Hospice Eligibility Determination" (Local Coverage Determination – guidelines used to determine if the patient is hospice appropriate) dated 6/2/2023, indicated ";Patient is eligible per LCD guidelines – Pulmonary Disease: 1 and 2 must be met. 2. Increased visits to ER? Yes, Hospitalization for pulmonary infections? Yes." During a joint home visit on 6/28/2023 at 10:30 a.m. with the Administrator (ADM) to P2s home, ADM stated that P2s sister-in-law is his caregiver and stated, ";She comes here often if they need something, she lives around here, right around the corner." P2 was noted sitting on single reclining sofa dressed watching television with a nasal canula in nose, receiving oxygen. P2 complained of right lower abdominal pain, ADM assisted P2 pull pants down and assessed pain and skin integrity. During an interview on 6/28/2023 at 12:51 p.m. with P2, P2 stated, ";Im sick but no one told me I will die in six months." During a concurrent interview and record review on 6/30/2023 at 2:05 p.m. with the Administrator (ADM) or P2s Electronic Medical Record (EMR), the ADM stated that she filled out P2s LCD but was unable to recall where she received the information from. ADM stated that there is no documentation to support P2 had increased emergency room visits or that he has been hospitalized for respiratory infections. ADM stated, ";Seems like none of them apply, after discussing the LCD with you I realize that none of them apply. Now that we review this, patient does not qualify for hospice services." During a telephone interview on 6/29/2023 at 2:28 p.m. with the Medical Doctor 2 (MD2), MD2 stated that he has not certified any patients for hospice care since December 2022. MD2 also stated, ";No, they did not call me to certify any patient they just called me for approval from the pharmacy." MD2 was asked about P2. MD2 stated, ";I dont recall him, I was probably not called regarding him." MD2 was asked about P1. MD2 stated, ";She doesnt sound familiar, I have not certified her for hospice benefits." During an interview on 6/30/2023 at 2:12 p.m. with the Administrator (ADM), the ADM stated MD2 has been an employee since April 2022 and that he has not been to the office. ADM also stated that she has been using his username and password to log into the facilitys Electronic Medical Record (EMR) with his permission. ADM stated, ";He gave me permission to enter the verbal report that he gave me and to sign on behalf of him." A review of facilitys policy and procedure titled, ";Responsibilities/Supervision of Clinical Services" dated May 2023, indicated ";Supervision of clinical care and services will be available 24 hours a day, seven (7) days a week. The Clinical Director will oversee the day-to-day clinical operations. The Clinical Director will monitor the care and services provided by hospice personnel and contract personnel." A review of facilitys policy and procedure titled, ";Certification of Terminal Illness" dated May 2023, indicated ";When certifying the patient as terminally ill, the hospice medical director...or physician designee must consider at least the diagnosis of the terminal condition of the patient, other health related conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. At the time of admission to hospice, the hospice Medical Director... or the patients attending physician will complete a certification narrative that reflect the patients individual circumstances based on: his/her review of the patients medical record... 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. Tools such as the fiscal intermediarys Local Coverage Determination, along with other supporting documentation, can be used to provide guidance in determining and documenting terminal prognosis." A review of facilitys policy and procedure titled, ";LCD – Hospice – Determining Terminal Status" undated, indicated ";Heart Disease – patients will be considered to be in the terminal stage of heart disease if they meet the following criteria. 1 and 2 should be present. 1. At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease... 2. Patients with congestive heart failure or angina shole meet the New York Heart Association (NYHA) Class IV. Class IV patients will heat disease have an inability to carry on any physical activity. Symptoms of heat failure of the anginal syndrome may be present even at rest. Pulmonary Disease - patients will be considered to be in the terminal stage of pulmonary disease if they meet the following criteria... 1 and 2 should be present. 1. Severe chronic lung disease as documented by both a and b. a. disabling dyspnea at rest...b. progression of end stage pulmonary disease, as evidence by increasing visits to the emergency department or hospitalization for pulmonary infections and/or respiratory failure. 2. Hypoxemia at rest on room air, as evidence by p02 less than or equal to 55 mmHg, or oxygen saturation less than or equal to 88%, determined either by arterial blood gases or oxygen saturation monitors." A review of facilitys policy and procedure titled, ";The Plan of Care" dated May 2023, indicated ";6. The hospice Medical Director will need to review the patients history and physical, which is also provided, to be able to sign the certification of terminal illness section of the plan of care. 8. Care decisions and services to be provided will be made as a result of the care planning process, analysis of initial and ongoing comprehensive assessments..." A review of facilitys policy and procedure titled, ";Admission Criteria and Process" dated May 2023, indicated ";The patients life-limiting illness and prognosis of six (6) months of less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCD). 1. The agency will admit a patient only on recommendation of the medical director in consultation with, or input from the patients attending physician... 3. The patient must have a life-limiting illness with a life expectancy of six (6) moths or less, as determined by the attending physician... utilizing standard clinical prognosis criteria in the organizations intermediary Local coverage Determination. 4. The patient must desire hospice services and be aware of the diagnosis and prognosis." A review of facilitys policy and procedure titled, ";Entries into the Clinical Record" dated May 2023, indicated ";Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. 1. A clinical record... will include at a minimum: C. Physician (or other license practitioner) orders and evidence of physician oversight activities."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation on Clinical Records was met as follows: 1. The HA failed to ensure there were physician orders for two of six sampled patients (Patient 2 and Patient 5). Patient 2 did not have an order for a skin ointment. Patient 5 did not have an order for wound care. (Refer to L678). 2. The HA failed to ensure any amendments, correction or late entries within an electronic health record clearly identified the original content, the modified content, date, and authorship of each record modification for four of six sampled patients (Patient 1, Patient 2, Patient 5, and Patient 6 ). The Administrator modified the physician's notes without indicating the date and the name/signature who modified the original content of the physician notes. (Refer to L679). 3. The HA failed to ensure contents and information in the patient's medical records were safeguarded from unauthorized access to make alterations and modifications for three of six sampled patients (Patient 1, Patient 2, and Patent 5). The HA's Administrator modified and documented on the physician's notes when the physician signed and did not have knowledge on the patients' health status. (Refer to L680). 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 failed to ensure there were physician orders for two of six sampled patients (Patient 2 and Patient 5). Patient 2 did not have an order for a skin ointment being provided by the HA and Patient 5 did not have an order for his wound. This failure resulted in an incomplete medical record and a potential confusion among staff, patient, and patient family/caregivers by not knowing what treatments were ordered by the patient's physician. --- . a. A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including chronic obstructive pulmonary disease (COPD-constriction of the airways and difficulty or discomfort in breathing). A review of P2s medical record form titled ";Comprehensive Nursing Assessment" dated 3/11/2023, indicated ";Some areas in the skin and still with noted dryness. Applied Vitamin A&D to the skin as ordered." A review of P2s medical record form titled ";POC/IDG (Plan of Care/Interdisciplinary Group) Review" dated 6/22/2023, indicated under section ";Integumentary/Skin – Apply Vitamin A&D ointment on dry skin and rashes as needed for skin treatment." Form also indicated it was signed by the Medical Director 2 (MD2), the Administrator (ADM). A review of P2s medical record form titled ";POC Summary" dated 6/22/2022, indicated there was no mentioned of Vitamin A&D ointment. A review of P2s medical record form titled ";Current Treatment/Medication/DME List" undated, indicated there was no mentioned of Vitamin A&D ointment. During a concurrent interview and record review 6/29/2023 at 12:30 p.m. with the ADM of P2s Electronic Medical Record (EMR), the EMR indicated there was no order for Vitamin A&D ointment. ADM stated, ";When the patient has dryness, we encourage them to use A&D for the dry skin. There is no order for A&D. Im not sure if the doctor knows that he uses A&D." ADM also stated that it was important for MD2 to be aware that P2 uses A&D, ";to know that its ok to apply the A&D." b. A record review of Patient 5s (P5) ";Personal Information", indicated P5 had a Start of Care (SOC) date of 3/20/2023 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). During an interview on 6/28/23, at 3:07 p.m., P5s caregiver (CG 2) stated a nurse was visiting from the HA to provide wound care, including dressing change. During a concurrent interview and record review on 6/30/23, at 11:37 a.m. P5s record titled, ";POC (Plan of Care) Summary", printed on 6/27/23, was reviewed with the ADM. The record did not indicate wound treatment orders. The ADM stated P5s wound care was being provided without a doctor orders. There should have been specific order for the wound care. When asked the reason for not having wound care orders, the ADM stated, ";we lack in that area. We have not put an actual order that is a deficiency." The ADM stated there was no documented evidence the doctor was aware of the wound and orders were provided for the wound management of P5.

Based on interview and record review the Hospice Agency (HA) failed to ensure any amendments, correction or late entries within an electronic health record clearly identified the original content, the modified content, date, and authorship of each record modification for four of six sampled patients (Patient 1, Patient 2, Patient 4, and Patient 5). The Administrator modified the physician's notes and did not indicate the date and name/signature of the modification. This failure has the potential to result in unauthorized and inaccurate patient information or assessments to be entered in the patient's clinical record. This had the potential to affect the patients quality of care and well-being. --- a. A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. A review of form ";Audit Log" dated 1/1/2023 to 6/30/2023, indicated the log was printed for P1, which included ";all staff" and under module ";Certification MD". It indicated: ---Modification Date: 6/27/2023 1:26:55 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Certification is based on Face to Face encounter; Current Value: true; Previous Value: false; Module ID: 1450649; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:26:55 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: tx Visit Date; Current Value: 06/02/0223; Previous Value: blank; Module ID: 1450649; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:26:55 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Physician Narrative Face to Face Summary (if applicable); Current Value: Patient is a 58 old female... ; Previous Value: blank; Module ID: 1450649; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:26:55 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Physician Narrative Certifying Physician Summary; Current Value: Patient is a 58 old female... ; Previous Value: blank; Module ID: 1450649; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:27:00 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Signed; Current Value: Reviewed and electronically signed by (MD2); Previous Value: Signature/Signature on file; Module ID: 1450649; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:27:00 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Date; Current Value: 06/02/2023; Previous Value: blank; Module ID: 1450649; IP Address: 45 51 119.195. A review of form ";Audit Log" dated 1/1/2023 to 6/30/2023, indicated the log was printed for P1, which included ";all staff" and under module ";IDG (Interdisciplinary Group". It indicated: ---Modification Date: 6/27/2023 1:14:21 PM; Staff: Medical Doctor 2; Module: IDG; Visit Date: 6/2/2023; Field/Section: Signed; Current Value: MD Signed... (MD2); Previous Value: blank; Module ID: 3088461; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:14:59 PM; Staff: Medical Doctor 2; Module: IDG; Visit Date: 6/22/2023; Field/Section: Signed; Current Value: MD Signed... (MD2); Previous Value: blank; Module ID: 3099887; IP Address: 45 51 119.195. b. A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including chronic obstructive pulmonary disease (COPD-constriction of the airways and difficulty or discomfort in breathing). A review of form ";Audit Log" dated 1/1/2023 to 6/30/2023, indicated the log was printed for P2, which included ";all staff" and under module ";Certification MD". It indicated: ---Modification Date: 6/27/2023 1:22:00 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Physician Narrative Certification Face to Face Summary (if applicable); Current Value: Patient is a 67 od male...; Previous Value: blank; Module ID: 1450650; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:22:00 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Physician Narrative Certifying Physician Summary; Current Value: Patient is a 67 od male...; Previous Value: blank; Module ID: 1450650; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:22:12 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Physician Narrative Certification Face to Face Summary (if applicable); Current Value: Signed; Previous Value: Signature/Signature on file; Module ID: 1450650; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:22:00 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Date; Current Value: 06/06/2023; Previous Value: blank; Module ID: 1450650; IP Address: 45 51 119.195. A review of form ";Audit Log" dated 1/1/2023 to 6/30/2023, indicated the log was printed for P2, which included ";all staff" and under module ";IDG (Interdisciplinary Group". It indicated: ---Modification Date: 6/27/2023 1:07:00 PM; Staff: Administrator; Module: IDG; Visit Date: 6/22/2023; Field/Section: Spiritual - Discussion; Current Value: decline, will continue to offer; Previous Value: blank; Module ID: 3099888; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:07:10 PM; Staff: Administrator; Module: IDG; Visit Date: 6/22/2023; Field/Section: Psychosocial - Discussion; Current Value: declined, will continue to offer; Previous Value: blank; Module ID: 3099888; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:07:24 PM; Staff: Administrator; Module: IDG; Visit Date: 6/22/2023; Field/Section: Signed; Current Value: RN signed on...; Previous Value: blank; Module ID: 3099888; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:11:23 PM; Staff: Medical Doctor 1; Module: IDG; Visit Date: 6/2/2023; Field/Section: Signed; Current Value: MD signed on...; Previous Value: blank; Module ID: 3088538; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:16:41 PM; Staff: Medical Doctor 2; Module: IDG; Visit Date: 6/22/2023; Field/Section: Telephone; Current Value: True; Previous Value: False; Module ID: 3099888; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:16:44 PM; Staff: Medical Doctor 2; Module: IDG; Visit Date: 6/22/2023; Field/Section: Signed; Current Value: MD signed on...; Previous Value: blank; Module ID: 3099888; IP Address: 45 51 119.195. During a concurrent interview and record review on 6/30/2023 at 2:12 p.m. with the Administrator (ADM), of P1 and P2s ";Audit Log", ADM stated that the Medical Director 2 (MD2) has been an employee since April 2022, and that he has not been to the office. ADM stated that he is involved in patient admissions and that she contacts him via the telephone. ADM stated that MD2 logs into their Electronic Medical Record (EMR) system to document when needed. The audit log was explained to the ADM. The ADM stated that she logs in on behalf of MD2 to document and sign, with his permission since he started working at facility. During a telephone interview on 6/29/2023 at 2:28 p.m. with the Medical Doctor 2 (MD2), MD2 stated that he has not certified any patients for hospice care since December 2022. MD2 also stated, ";No, they did not call me to certify any patient they just called me for approval from the pharmacy." MD2 was asked about P2. MD2 stated, ";I dont recall him, I was probably not called regarding him." MD2 was asked about P1. MD2 stated, ";She doesnt sound familiar, I have not certified her for hospice benefits." c. A record review of Patient 5s (P5) ";Personal Information", indicated P5 had a Start of Care (SOC) date of 3/20/2023 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). During a concurrent interview and record review on 6/30/23, at 1:40 p.m., P5s record titled ";Audit Log", dated 1/1/23 to 6/30/23, was reviewed with the administrative designee (AD). The record indicated that on 6/7/23, ";module Certification MD (CTI-certificate of terminal illness) for date 6/18/23, field/section Physician Narrative" was written by Medical Director 3 (MD 3). AD 1 stated she had documented ";Please see attached" under the physician narrative section of the document. The AD did not provide an explanation why her name did not appear as the author in the Audit Log. d. A record review of Patient 6s (P6) ";Personal Information", indicated P6 had a Start of Care (SOC) date of 1/30/2023 and an End of Care (EOC) date of 2/16/2023, with a primary diagnoses including heart failure (when the heart doesnt pump enough blood for the bodys needs). During a concurrent interview and record review on 6/30/23, at 1:33 p.m., P6s record titled ";Audit Log" dated 1/1/23 to 6/30/23, was reviewed with the administrative designee (AD). The record indicated that on 2/3/23, ";Module Certification MD (CTI-certificate of terminal illness) for date 1/30/23, field/section Physician Narrative" was written by Medical Director 1 (MD 1). AD 1 stated she had documented the physician narrative for MD 1. AD stated MD 1 had logged in the electronic medical record (EMR), opened the module and the AD typed the narrative. The AD did not provide an explanation for entering the physician narrative for MD 1. A review of P6s record titled, ";Physicians Certification for Hospice Benefit (CTI)", dated 1/30/23, indicated, ";Medical Director Attestation/Certification: I attest/confirm that I composed this narrative and reviewed and electronically signed by MD 1. The record did not indicate the AD was the author of the note. A review of facilitys policy and procedure titled, ";Access Controls: Technical Safeguards" dated May 2023, indicated ";The agency will ensure that access to ePHI system is granted to workforce members using unique user identifiers. A review of the facilitys policy and procedure titled, ";HIPPA Security Audit Controls" dated May 2023, indicated the agency will take appropriate steps to protect the integrity of ePHI that it creates, receives, maintains or transmits from unauthorized modification or destruction." A review of facilitys policy and procedure titled, ";Person or Entity Authentication" dated May 2023, indicated the agency will use appropriate authentication methods to confirm that only properly authenticated and authorized persons or entities access ePHI. Appropriate access methods may include a unique user identifiers and user identifiers. A review of facilitys policy and procedure titled, ";Entries into the Clinical Record" dated May 2023, indicated documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. The clinical record will include at a minimum: Physician (or other licensed practitioner) orders and evidence of physician oversight activities. Entries into the clinical record will be made on the date care is provided to the patient. All documentation will be turned in to the office within seven (7) days. The clinical note will include Signature of clinician and his/her credentials. All entries into the clinical record will reflect the date care was provided, including the time, month, day, and year. Late entries and amendments will be documented, stating ";late entry or amendment for visit of (date and time of visit). Amendments, corrections or late entries within an electronic health record must: Distinctly identify any amendment, correction or late entry. 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. A review of facilitys undated policy and procedure titled, ";Clinical Data Collection Review" indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services.

Based on interview and record review the Hospice Agency (HA) failed to ensure contents and information in the patient's medical records are safeguarded from unauthorized access to make alterations and modifications on the patients' physician's notes for three of six sampled patients (Patient 1, Patient 2, and Patient 5 ). The Administrator modified the physician notes when the physician signed and did not know the patient health status. This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients clinical record that could affect the patients quality of care and well-being. --- . a. A record review of Patient 1s (P1) ";Personal Information", indicated P1 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including hypertensive (high blood pressure) heart disease without heart failure. A review of form ";Audit Log" dated 1/1/2023 to 6/30/2023, indicated the log was printed for P1, which included ";all staff" and under module ";Certification MD". It indicated: ---Modification Date: 6/27/2023 1:26:55 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Certification is based on Face to Face encounter; Current Value: true; Previous Value: false; Module ID: 1450649; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:26:55 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: tx Visit Date; Current Value: 06/02/0223; Previous Value: blank; Module ID: 1450649; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:26:55 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Physician Narrative Face to Face Summary (if applicable); Current Value: Patient is a 58 old female...; Previous Value: blank; Module ID: 1450649; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:26:55 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Physician Narrative Certifying Physician Summary; Current Value: Patient is a 58 old female...; Previous Value: blank; Module ID: 1450649; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:27:00 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Signed; Current Value: Reviewed and electronically signed by (MD2); Previous Value: Signature/Signature on file; Module ID: 1450649; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:27:00 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Date; Current Value: 06/02/2023; Previous Value: blank; Module ID: 1450649; IP Address: 45 51 119.195. A review of form ";Audit Log" dated 1/1/2023 to 6/30/2023, indicated the log was printed for P1, which included ";all staff" and under module ";IDG (Interdisciplinary Group". It indicated: ---Modification Date: 6/27/2023 1:14:21 PM; Staff: Medical Doctor 2; Module: IDG; Visit Date: 6/2/2023; Field/Section: Signed; Current Value: MD Signed... (MD2); Previous Value: blank; Module ID: 3088461; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:14:59 PM; Staff: Medical Doctor 2; Module: IDG; Visit Date: 6/22/2023; Field/Section: Signed; Current Value: MD Signed... (MD2); Previous Value: blank; Module ID: 3099887; IP Address: 45 51 119.195. b. A record review of Patient 2s (P2) ";Personal Information", indicated P2 had a Start of Care (SOC) date of 3/11/2023 with a primary diagnoses including chronic obstructive pulmonary disease (COPD-constriction of the airways and difficulty or discomfort in breathing). A review of form ";Audit Log" dated 1/1/2023 to 6/30/2023, indicated the log was printed for P2, which included ";all staff" and under module ";Certification MD". It indicated: ---Modification Date: 6/27/2023 1:22:00 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Physician Narrative Certification Face to Face Summary (if applicable); Current Value: Patient is a 67 od male...; Previous Value: blank; Module ID: 1450650; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:22:00 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Physician Narrative Certifying Physician Summary; Current Value: Patient is a 67 od male...; Previous Value: blank; Module ID: 1450650; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:22:12 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Physician Narrative Certification Face to Face Summary (if applicable); Current Value: Signed; Previous Value: Signature/Signature on file; Module ID: 1450650; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:22:00 PM; Staff: Medical Doctor 2; Module: Certification MD; Visit Date: 6/9/2023; Field/Section: Date; Current Value: 06/06/2023; Previous Value: blank; Module ID: 1450650; IP Address: 45 51 119.195. A review of form ";Audit Log" dated 1/1/2023 to 6/30/2023, indicated the log was printed for P2, which included ";all staff" and under module ";IDG (Interdisciplinary Group". It indicated: ---Modification Date: 6/27/2023 1:07:00 PM; Staff: Administrator; Module: IDG; Visit Date: 6/22/2023; Field/Section: Spiritual - Discussion; Current Value: decline, will continue to offer; Previous Value: blank; Module ID: 3099888; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:07:10 PM; Staff: Administrator; Module: IDG; Visit Date: 6/22/2023; Field/Section: Psychosocial - Discussion; Current Value: declined, will continue to offer; Previous Value: blank; Module ID: 3099888; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:07:24 PM; Staff: Administrator; Module: IDG; Visit Date: 6/22/2023; Field/Section: Signed; Current Value: RN signed on...; Previous Value: blank; Module ID: 3099888; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:11:23 PM; Staff: Medical Doctor 1; Module: IDG; Visit Date: 6/2/2023; Field/Section: Signed; Current Value: MD signed on...; Previous Value: blank; Module ID: 3088538; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:16:41 PM; Staff: Medical Doctor 2; Module: IDG; Visit Date: 6/22/2023; Field/Section: Telephone; Current Value: True; Previous Value: False; Module ID: 3099888; IP Address: 45 51 119.195. ---Modification Date: 6/27/2023 1:16:44 PM; Staff: Medical Doctor 2; Module: IDG; Visit Date: 6/22/2023; Field/Section: Signed; Current Value: MD signed on...; Previous Value: blank; Module ID: 3099888; IP Address: 45 51 119.195. During a concurrent interview and record review on 6/30/2023 at 2:12 p.m. with the Administrator (ADM), of P1 and P2s ";Audit Log", ADM stated that the Medical Director 2 (MD2) has been an employee since April 2022, and that he has not been to the office. ADM stated that he is involve in patient admissions and that she contacts him via the telephone. ADM stated that MD2 logs into their Electronic Medical Record (EMR) system to document when needed. The audit log was explained to the ADM. The ADM stated that she logs in on behalf of MD2 to document and sign, with his permission since he started working at facility. During a telephone interview on 6/29/2023 at 2:28 p.m. with the Medical Doctor 2 (MD2), MD2 stated that he has not certified any patients for hospice care since December 2022. MD2 also stated, ";No, they did not call me to certify any patient they just called me for approval from the pharmacy." MD2 was asked about P2. MD2 stated, ";I dont recall him, I was probably not called regarding him." MD2 was asked about P1. MD2 stated, ";She doesnt sound familiar, I have not certified her for hospice benefits." c. A record review of Patient 5s (P5) ";Personal Information", indicated P5 had a Start of Care (SOC) date of 3/20/2023 with a primary diagnoses including atherosclerotic heart disease of native coronary artery without angina pectoris (a buildup of plaque inside the artery walls affecting the arteries that supply the heart with blood). During a concurrent interview and record review on 6/30/23, at 1:40 p.m., P5s record titled ";Audit Log", dated 1/1/23 to 6/30/23, was reviewed with the administrative designee (AD). The record indicated that on 6/7/23, ";module Certification MD (CTI-certificate of terminal illness) for date 6/18/23, field/section Physician Narrative" was written by Medical Director 3 (MD 3). AD 1 stated she had documented ";Please see attached" under the physician narrative section of the document. The AD stated she did not know what happened, she didnt know if she had stay logged on and some one else came in and documented on P5s record. A review of facilitys policy and procedure titled, ";Access Controls: Technical Safeguards" dated May 2023, indicated ";The agency will ensure that access to ePHI system is granted to workforce members using unique user identifiers..." A review of facilitys policy and procedure titled, ";HIPPA Security Audit Controls" dated May 2023, indicated ";The agency will take appropriate steps to protect the integrity of ePHI that it creates, receives, maintains or transmits from unauthorized modification or destruction." A review of facilitys policy and procedure titled, ";Person or Entity Authentication" dated May 2023, indicated ";The agency will use appropriate authentication methods to confirm that only properly authenticated and authorized persons or entities access ePHI. Appropriate access methods may include: A. Unique user identifiers B. User identifiers A review of facilitys policy and procedure titled, ";Entries into the Clinical Record" dated May 2023, indicated ";Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. 1. A clinical record... will include at a minimum: C. Physician (or other license practitioner) orders and evidence of physician oversight activities. 6. Entries into the clinical record will be made on the date care is provided to the patient. All documentation will be turned in to the office within seven (7) days. 7. The clinical note will include: E. Signature of clinician and his/her credentials. 10. All entries into the clinical record will reflect the date care was provided, including the time, month, day, and year. 12. Late entries and amendments will be documented, stating ";late entry or amendment for visit of (date and time of visit) ...14. Amendments, corrections or late entries within an electronic health record must: A. Distinctly identify any amendment, correction or late entry. 16. 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." A review of facilitys policy and procedure titled, ";Clinical Data Collection Review" undated, indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services."

Based on interview and record review, the Hospice Agency (HA) failed to ensure to provide core services by ensuring the Medical Social Worker (MSW) was a facility employee. The facility also failed to ensure their Baccalaureate Social Worker (BSW) was overseen by the MSW for one of six sampled patients (Patient 4). This failure resulted in the patient being evaluated by an unqualified employee and had the potential to result in the patients psychosocial needs not being met. --- A record review of Patient 4s (P4) ";Personal Information" indicated P4 had a Start of Care (SOC) date of 2/9/2023 with primary diagnoses that included hypertensive (high blood pressure) heart disease without heart failure (a chronic condition in which the heart muscle does not pump enough blood to meet the body's needs). During a telephone interview on 6/28/2023 at 12:11 p.m. with the MSW, the MSW stated that she has been working at the facility since ";2022 or 2023" as a per diem contracted employee, who holds a W9 status. MSW stated that her responsibilities were to assess patients psychological and environmental needs. During a telephone interview on 6/29/2023 at 1:42 p.m. with the Baccalaureate Social Worker (BSW), the BSW stated, ";I do initial assessment, home assessment, any psychosocial needs. I provide services support, resources in the community. I am currently working as a social worker at an adult care center and for hospice she is dealing with patients with their diagnosis and end of life. So, we are trying to ease their worries and help them, encourage them to be strong to continue with their life." BSW stated that she does not hold an MSW degree. BSW stated, ";I do the psychosocial independently. I have the MSW look at them." The BSW stated she had seen P4 in February 2023 to complete the psychosocial assessment. During a telephone interview on 6/30/2023 at 10:15 a.m. with the MSW, the MSW stated that she has supervised the BSW once. MSW stated, ";Ive done it maybe one or two times out of courtesy. I supervised BSW a couple months ago. It was by phone. I looked through her documentation and gave my opinion and my thoughts. I dont really consider myself a supervisor, that is not really my area of expertise. Ive supervised her once." During an interview on 6/30/2023 at 3:00 p.m. with the Administrator Designee (AD), the AD stated that the MSW was a per diem W9 employee. A record review of P4s record titled, "Psychosocial Assessment" dated 2/10/2023, indicated, the Narrative Psychosocial Assessment was completed by SW and electronically signed by BSW on 2/10/23. A review of facilitys form titled ";Application Information" dated 7/15/2022, indicated the MSWs name and personal information was documented on the form. It also indicated the form was signed by the MSW. A review of facilitys form titled ";Employment Agreement: Per Diem/Salary/Hourly" dated 7/15/2022, indicated the MSWs name and personal information was documented in the form. It also indicated the form was singed by the MSW and the AD. A review of facilitys form titled ";W-9" dated 7/15/2022, indicated the MSWs name and personal information was documented in the form. It also indicated the form was signed by the MSW. A review of facilitys undated form titled ";Organizational Chart", indicated the MSWs name was in the form as their MSW. A review of facilitys undated public brochure, indicated care is provided by an Interdisciplinary Team of Hospice-trained professional including the physician, clinical Social Worker and non-denominational chaplains. A review of facilitys policy and procedure titled, ";Psychosocial Assessment" dated May 2023, indicated an in-depth psychosocial assessment will be completed by a qualified hospice social worker or registered nurse. After the assessment is performed, ongoing contact will be maintained by phone and/or home visits by the Hospice social worker." A review of facilitys policy and procedure titled, ";Responsibilities/Supervision of Clinical Services" dated May 2023, indicated supervision of clinical care and services will be available 24 hours a day, seven (7) days a week. The Clinical Director will oversee the day-to-day clinical operations. The Clinical Director will monitor the care and services provided by hospice personnel and contract personnel. Social worker (baccalaureate prepared) supervision will be completed by a masters prepared medical social worker at least every 30 days. A review of the facilitys policy and procedure titled, ";Initial Assessment" dated May 2023, indicated the 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."