Every finding on record at Community First Hospice Care, Inc.

The hospice must conduct and document in writing a patient-specific comprehensive assessment that identifies the patient's need for hospice care and services, and the patient's need for physical, psychosocial, emotions and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions. --- Based on record reviews and interviews, the hospice agency failed to ensure that the IDG (Interdisciplinary Group) in collaboration with the individuals attending physician revised/updated the Comprehensive Assessments as frequently as the condition of the patient requires, at least every 15 days, as determined by changes in the patients condition for nine of nine active patients (#1, #6, #9, #11, #12, #14, #16, #19 and #21) and one of one discharged patient (#24) whose records were reviewed. Related to L0533

Based on record reviews and interviews, the hospice agency failed to ensure that the IDG (Interdisciplinary Group) in collaboration with the individuals attending physician revised/updated the Comprehensive Assessments as frequently as the condition of the patient requires, at least every 15 days, as determined by changes in the patients condition for nine of nine active patients (#1, #6, #9, #11, #12, #14, #16, #19 and #21) and one of one discharged patient (#24) whose records were reviewed in that:. Patients #1, #6, #9, #11, #12, #14, #16, #19 and #21 and #24 did not have signatures of the IDG team members and the attending physicians signature to demonstrate active and collaborative participation in the update of the comprehensive assessment. This failure resulted in Patients #1, #6, #9, #11, #12, #14, #16, #19, #21 and #24s comprehensive assessment not being updated within the required timeframe by the IDG team members and the patients attending physician. This failure placed the agencys 23 active hospice patients at risk of receiving care that does not meet the patients current needs, and dying without dignity, and had the likelihood to cause serious harm, neglect and deterioration in the patients condition and would seriously impact the agencys 23 hospice patients and families. --- The findings included: Review of Patient #1's electronic clinical record (ECR) revealed a SOC date 04/22/22 with a terminal illness diagnosis of atherosclerotic heart disease, for the certification period of 09/16/22 to 11/16/22. Further review of Patient #1's ECR revealed the IDG met to update the comprehensive assessments as follows: 09/24/22 and 10/05/22. Further review revealed no documented evidence that Patient #1's the IDG/POC was updated at least every 15 days. Review of Patient #6s ECR revealed a SOC date of 04/25/22 with a terminal illness diagnosis of Hypertensive Hear Disease with Chronic Kidney Disease, for the certification period of 10/03/22 to 12/01/22. Further review of Patient #6s ECR revealed the IDG met to update the comprehensive assessments as follows: 10/05/22. Further review revealed no documented evidence that Patient #6's the IDG/POC was updated at least every 15 days. Review of Patient #24s discharged ECR revealed a SOC date of 04/25/22 with a terminal illness diagnosis of Senile Degeneration of the Brain, for the certification period of 10/14/22 – 10/24/22. Further review of Patient #24s ECR revealed the IDG met to update the comprehensive assessment as follows: 10/05/22. Further review revealed no documented evidence that Patient #24's the IDG/POC was updated at least every 15 days. Review of patient #9s ECR revealed a SOC date of 04/27/22 with a terminal illness diagnosis of Cardiomegaly, for the certification period of 10/11/22 to 12/09/22. Further review of Patient #9s revealed that the last updated comprehensive assessment was completed on 10/05/22. Further review revealed no documented evidence that Patient #9's the IDG/POC was updated at least every 15 days. Review of Patient #11s ECR revealed a SOC date of 04/21/22 with a terminal illness diagnosis of Senile Dementia of the Brain for the certification period of 08/30/22 to 10/28/22. Further review of Patient #11s ECR revealed the IDG met to update the comprehensive assessment as follows: 09/09/22, 09/21/22 and10/05/22. Further review revealed no documented evidence that Patient #11's the IDG/POC was updated at least every 15 days. Review of Patient #12s ECR revealed a SOC date of 09/14/22 with a terminal illness diagnosis of Senile Degeneration of the Brain, for the certification period of 09/14/22 to 11/12/22. Further review of Patient #12s ECR revealed the IDG met to update the comprehensive assessment as follows: 09/21/22 and10/05/22. Further review revealed no documented evidence that Patient #12's the IDG/POC was updated at least every 15 days. Review of Patient #14s ECR revealed a SOC date of 04/21/22 with a terminal illness diagnosis of Cirrhosis of the Liver, for certification period of 09/10/22 to 11/08/22. Further review of Patient #14s ECR revealed the IDG met to update the comprehensive assessment as follows: 09/21/22 and10/05/22. Further review revealed no documented evidence that Patient #14's the IDG/POC was updated at least every 15 days. Review of Patient #16s ECR revealed a SOC date of 08/21/22, with a terminal illness diagnosis of Senile Dementia of the Brain, for the certification period of 08/21/22 to 11/18/22. Further review of Patient #16s ECR revealed the IDG met to update the comprehensive assessment as follows: 08/24/22, 09/07/22, 09/21/22 and10/05/22. Further review revealed no documented evidence that Patient #16's the IDG/POC was updated at least every 15 days. Review of Patient #19s ECR revealed a SOC date pf 08/16/22, with a terminal illness diagnosis of Chronic Kidney Disease Stage 2 for the certification period of 08/16/22 to Further review of Patient #19s ECR revealed the IDG met to update the comprehensive assessment as follows: 08/24/22, 09/07/22, 09/21/22 and10/05/22. Further review revealed no documented evidence that Patient #19's the IDG/POC was updated at least every 15 days. Review of Patient #21s ECR revealed a SOC date of 04/25/22, with a terminal illness diagnosis of Chronic Obstructive Pulmonary Disease for the certification period of 10/08/22 to 12/03/22. Further review of Patient #21s ECR revealed the IDG met to update the comprehensive assessment as follows: 09/21/22 and10/05/22. Further review revealed no documented evidence that Patient #21's the IDG/POC was updated at least every 15 days. During an interview on 10/25/22 at 11:55 a.m., the Medical Director stated, ";that she is concerned for the agencys hospice patients and contacted the accrediting agency to seek guidance on the matter...that the Alternate Administrator/Director of Nurses (AA/DON) had resigned from the agency...that the Administrator/Alternate DON (A/ADON) is not answering calls or text messages and will only contact staff members to put out information and is not available to discuss issues/concerns regarding patient care." The Medical Director stated, that the IDG meeting was supposed to be held on 10/19/22 but was rescheduled for 10/20/22...The Medical Director stated that the IDG meeting was not held on 10/20/22...All IDG team members were present at the designated location for six hours and A/ADON was a no-show...Meeting was not held."...The Medical Director further stated ";that the A/ADON had to schedule the IDG team meeting at another location due to a restraining order filed by the owner of the building where the agency rents an office space; and added that both the Owner of the agency and the A/ADON are prohibited from entering the building." During an interview 11/02/22 at 10:20 a.m., the Administrator/ADON stated that IDG meetings are held every other Wednesday for all patients. She stated no, the agency did not conduct an ";actual" IDG meeting to update the patients comprehensive assessment as required during the week of 10/16/22. She stated that she did try to conduct an IDG meeting on 10/19/22 at 9:00 a.m., with the IDG team via ZOOM, which included the Medical Director, Chaplains E and F, the MSW, RN G, RN H and RN I. She stated that the IDG team refused to participate in the meeting unless, the Administrator/ADON had their paychecks (bank cashiers check). She stated that because she did not have their paychecks, and the IDG Meeting was rescheduled for 10/20/22 at a conference room located at a local hotel, and that she would participate via ZOOM; with the assurance that they would receive their paychecks. She stated that the IDG team met on 10/20/22 at the conference room at the local hotel but because she was unable to get the paychecks for the staff as promised the IDG team refused to participate in the IDG meeting and sign the updated comprehensive assessments. She stated that on 10/20/22, the owner had the bank cashiers checks to give to the staff as promised, that he was in a car accident and had another individual come in another car, get the bank cashiers check from the agency Owner to take to agency staff at the designated location for the IDG meeting. However, the individual in route to the designated location stopped at a local convenience store where his car was stolen along with the bank cashiers checks to pay the employees." Review of the agencys policy titled, ";PE.1 Patient Assessments", revised date 01/01/20, read in part ";...C. The update to the comprehensive assessment will be completed as frequently as the condition of the patient requires, but no less frequently than every 15 days." Review of the agencys policy titled, ";PC.8 Interdisciplinary Group Roles and Responsibilities", revised date 12/02/19, read in part ";...IV. IDG meetings will be held...at least every 15 days...V. The IDG will update the comprehensive assessment no less frequently than every 15 days." On 10/28/22 at 6:15 p.m., the A/ADON was informed that an Immediate Jeopardy was identified related to Management Responsibility, Financial Solvency, Review of the Hospice Plan of Care, and Coordination of Care. On 11/03/22 at 12:42 .m., the Administrator was notified an immediacy no longer exited as the agency discharged all 23 patients. Immediate Action Taken: On October 26, 2022, at 10:00 a.m., the A/ADON of [Agencys Name Hospice A] met with the Owner to review the current situation. The A/ADON persuaded the Owner that we [Agencys Name] to continue to provide the best quality care for our patients [patients]we would have to transfer patients to other hospice agencies. This in turn would guarantee the continued quality of care to the patients [patients]. On 10/26/22, the A/ADON contacted another local [Hospice Agency B] to inquire if they [Hospice B] would be willing to admit/transfer patients of [Hospice Agency A] who choose to have the [Hospice Agency B] service their need. The [Hospice Agency B] agreed to admit/transfer any patients of [Hospice Agency A]. On 10/26/22 at 5:30 p.m., the A/ADON started calling patients/patients/families of Hospice Agency A to inform them that Hospice Agency A will assist them in finding a new hospice agency to provide their care; that they [Hospice A patient/patients] had a choice of hospice agencies, that Hospice A spoke with Hospice B and that Hospice B would be able to admit/transfer [Hospice As patient/patients]; that MSW and Chaplain services would be available for emergencies. The following list have a communication note entered in Hospice As ECR (electronic clinical record). (10/26/22) 5:57 p.m., Patient #2 was called and agreed to try Hospice B. 5:56 p.m., Patient #4 was called and agreed to try Hospice B. 6:00 p.m., Patient #5 was called...message left. 6:10 p.m., Patient #6 was called and agreed to try Hospice B. 6:15 p.m., Patient #7s family member (FM) was called and stated, you need to go see Patient #7, he will not answer the phone. 6:24 p.m., Patient #8 left message with FM/MPOA (medical power of attorney) 6:45 p.m., Patient #19 was called and agreed to try Hospice B. 6:50 p.m., Patient #1 was called and agreed to try Hospice B. 6:59 p.m., Patient #10 was called and agreed to try Hospice B. 7:06 p.m., Patient #11s FM was called stated that she will find another hospice agency...A/ADON informed Patient #11s FM that she would follow up on 10/27/22 or the next day. 7:13 p.m., Patient #13 was called and agreed to try Hospice B. 7:20 p.m., Patient #14 was called and agreed to try Hospice B. 7:27 p.m., Patient 15s FM was called and agreed to try Hospice B. 7:31 p.m., Patient #16s FM was called and agreed to try Hospice B. 7:39 p.m., Patient #18 was called and agreed to try Hospice B. 7:43 p.m., Patient 20 was called and agreed to try Hospice B. 7:50 p.m., Patient #21s FM was called and agreed to try Hospice B. 7:54 p.m., Patient #22s FM was called, and a message was left. 8:00 pm., Patient #23s FM was called, and a message was left. On 10/27/2022: 8:10 a.m., Patient #17s FM was seen in person and agreed to try Hospice B. 8:19 a.m., Patient #22s FM was called, and left message. 8:23 a.m., Patient #22s FM agreed to try Hospice B. 11:00 a.m., Patient #9s FM seen in person and will let A/ADON know their decision. 11:30 a.m., Patient #23s FM stated that there was a problem with communication did not understand the message...Patient #23s FM agreed to Hospice B coming to discuss their services with the patient. 12:31 p.m., Patient #8s FM called and stated he will let A/ADON know of decision. 12:52 p.m., Patient #18 was seen in person by the A/ADON and agreed to try Hospice B. 12:57 p.m., Patient #12s FM was called and agreed to try Hospice B. 1:14 p.m., Patient #3s FM was called and agreed to try Hospice B. 3:00 p.m., Patient #8s FM called and agreed to try Hospice B. 3:10 p.m., Patient #11s FM agreed to try Hospice B. On 10/28/22: Hospice C informed Hospice A that Patient #9 decided to go with them. Follow-up Action Taken: On 10/27/2022 the Letter of Agreement/ Contingency Plan was signed by Receiving Agency Hospice Bs Owner and Closing Agency Hospice A A/ADON. Hospice B transferred three patients on 10/27/2022. Hospice B transferred eleven patients on 10/28/2022. Hospice B is pending transfer of five patients on 10/31/2022. Hospice B is pending transfer of two patients on 11/01/2022. Patient #9s FM choose to go to Hospice C. October 31, 2022: Patient #8 transferred to Hospice B Patient #14 transferred to Hospice B Patient #18 transferred to Hospice B November 1, 2022: Patient #4s FM revoked (cancelled hospice services), declined assistance with services. Patient #6 transferred to Hospice B Patient #15 revoked hospice services, will place patient in skilled facility Patient #21 transferred to Hospice B. Patient #22 transferred to Hospice B Patient #23 transferred to Hospice B November 03, 2022: Patient #10 pending transfer on 11/03/2022 to Hospice B A/ADON will follow up with Hospice C on 10/31/2022. A/ADON will follow up with the following patients family: Patient #14, Patient #21, and Patient #5, on their choice of Hospice agencies 10/31/2022. Hospice A is planning on all patients in their care to be transferred or admitted to another hospice agency by 11/03/2022 Plan Going Forward: Hospice A will see that all patients are removed and transferred to another hospice agency. Hospice A will proceed with suspending license and/or closing agency. Hospice A Staff will be paid once CMS has made payments to Hospice A. Hospice As Clinical records and staff charts will remain with owner [Hospice As owner].

The hospice must designate an interdisciplinary group (IDG) or groups as specified in paragraph (a) of this section which, in consultation with the patient's attending physician, must prepare a written plan of care for each patient. --- Based on record review and an interview, the hospice failed to ensure the Interdisciplinary Group (IDG) plans of care (POC) were signed by members of the IDG for nine of nine active patients (#1, #2, 3, #4, #5, #6, #7 and #8) and one of one discharged patient (#24) whose records were reviewed. Refer to L-0537 Based on record review and interview, the hospice interdisciplinary group (IDG) in collaboration with the individuals attending physician failed to review, revise, and document the individualized plan at least every 15 calendar days for nine of nine active patients (#1, #6, #9, #11, #12, #14, #16, #19 and #21) and one of one discharged patient (#24) records whose records were reviewed. Refer to L-0552 Based on record reviews and interviews, the agency failed to maintain a system of communication and integration, in accordance with the hospices own written policies to ensure the ongoing sharing of information between all disciplines providing care and services for nine of nine active patients (#1, #6, #9, #11, #12, #14, #16, #19 and #21) and one of one discharged patient (#24) whose clinical records were reviewed. Refer to L-0557

Based on record review and an interview, the hospice failed to ensure the Interdisciplinary Group (IDG) plans of care (POC) were signed by members of the IDG for nine of nine active patients (#1, #2, 3, #4, #5, #6, #7 and #8) and one of one discharged patient (#24) whose records were reviewed in that: Patients #1, #6, #9, #11, #12, #14, #16, #19 and #21 and #24 did not have signatures of the IDG team members and the attending physicians signature to demonstrate active and collaborative participation in the review of each patients POC to ensure that any changes in conditions were identified, discussed and coordinated among the IDG team members and the attending physician. This failure resulted in Patients #1, #6, #9, #11, #12, #14, #16, #19, #21 and #24s comprehensive assessment not being updated within the required timeframe by the IDG team members and the patients attending physician. This failure placed the agencys 23 active hospice patients at risk of receiving care that does not meet the patients current needs, dying without dignity and had the likelihood to cause serious harm, neglect and deterioration in the patients condition and would seriously impact the agencys 23 hospice patients and families. --- The findings included: Review of the agencys policy titled, ";PC.22 Coordination of Care" revised date 05/01/19, read in part, ";...IV. The IDG (interdisciplinary group) will maintain responsibility for directing, coordinating, and supervising the care and services provided by all medical entities...VI. The IDG will ensure that the care and services provided are based on all assessments of the patient and familys needs and are provided in accordance with the POC (plan of care) ...VII. All communication and coordination of care is documented in the clinical record." Review of Patient #1's electronic clinical record (ECR) revealed a SOC date 04/22/22 with a terminal illness diagnosis of atherosclerotic heart disease, for the certification period of 09/16/22 to 11/16/22. Further review of Patient #1's ECR revealed the IDG met to update the comprehensive assessments as follows: 09/24/22 and 10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #6s ECR revealed a SOC date of 04/25/22 with a terminal illness diagnosis of Hypertensive Hear Disease with Chronic Kidney Disease, for the certification period of 10/03/22 to 12/01/22. Further review of Patient #6s ECR revealed the IDG met to update the comprehensive assessments as follows: 10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #24s discharged ECR revealed a SOC date of 04/25/22 with a terminal illness diagnosis of Senile Degeneration of the Brain, for the certification period of 10/14/22 – 10/24/22. Further review of Patient #24s discharged ECR revealed the IDG met to update the comprehensive assessment as follows: 10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #9s ECR revealed a SOC date of 04/27/22 with a terminal illness diagnosis of Cardiomegaly, for the certification period of 10/11/22 to 12/09/22. Further review of Patient #9s revealed that the last updated comprehensive assessment was completed on 10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #11s ECR revealed a SOC date of 04/21/22 with a terminal illness diagnosis of Senile Dementia of the Brain for the certification period of 08/30/22 to 10/28/22. Further review of Patient #11s ECR revealed the IDG met to update the comprehensive assessment as follows: 09/09/22, 09/21/22 and 10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #12s ECR revealed a SOC date of 09/14/22 with a terminal illness diagnosis of Senile Degeneration of the Brain, for the certification period of 09/14/22 to 11/12/22. Further review of Patient #12s ECR revealed the IDG met to update the comprehensive assessment as follows: 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #14s ECR revealed a SOC date of 04/21/22 with a terminal illness diagnosis of Cirrhosis of the Liver, for certification period of 09/10/22 to 11/08/22. Further review of Patient #14s ECR revealed the IDG met to update the comprehensive assessment as follows: 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #16s ECR revealed a SOC date of 08/21/22, with a terminal illness diagnosis of Senile Dementia of the Brain, for the certification period of 08/21/22 to 11/18/22. Further review of Patient #16s ECR revealed the IDG met to update the comprehensive assessment as follows: 08/24/22, 09/07/22, 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #19s ECR revealed a SOC date pf 08/16/22, with a terminal illness diagnosis of Chronic Kidney Disease Stage 2 for the certification period of 08/16/22 to Further review of Patient #19s ECR revealed the IDG met to update the comprehensive assessment as follows: 08/24/22, 09/07/22, 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #21s ECR revealed a SOC date of 04/25/22, with a terminal illness diagnosis of Chronic Obstructive Pulmonary Disease for the certification period of 10/08/22 to 12/03/22. Further review of Patient #21s ECR revealed the IDG met to update the comprehensive assessment as follows: 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. During an interview on 10/25/22 at 11:55 a.m., the Medical Director stated, ";that she is concerned for the agencys hospice patients and contacted the accrediting agency to seek guidance on the matter...that the Alternate Administrator/Director of Nurses (AA/DON) had resigned from the agency...that the Administrator/Alternate DON (A/ADON) is not answering calls or text messages and will only contact staff members to put out information and is not available to discuss issues/concerns regarding patient care." The Medical Director stated, that the IDG meeting was supposed to be held on 10/19/22 but was rescheduled for 10/20/22...The Medical Director stated that the IDG meeting was not held on 10/20/22...All IDG team members were present at the designated location for six hours and A/ADON was a no-show...Meeting was not held."...The Medical Director further stated ";that the A/ADON had to schedule the IDG team meeting at another location due to a restraining order filed by the owner of the building where the agency rents an office space; and added that both the Owner of the agency and the A/ADON are prohibited from entering the building." During an interview 11/02/22 at 10:20 a.m., the Administrator/ADON stated that IDG meetings are held every other Wednesday for all patients. She stated no, the agency did not conduct an ";actual" IDG meeting to update the patients comprehensive assessment as required during the week of 10/16/22. She stated that she did try to conduct an IDG meeting on 10/19/22 at 9:00 a.m., with the IDG team via ZOOM, which included the Medical Director, Chaplains E and F, the MSW, RN G, RN H and RN I. She stated that the IDG team refused to participate in the meeting unless, the Administrator/ADON had their paychecks (bank cashiers check). She stated that because she did not have their paychecks, and the IDG Meeting was rescheduled for 10/20/22 at a conference room located at a local hotel, and that she would participate via ZOOM; with the assurance that they would receive their paychecks. She stated that the IDG team met on 10/20/22 at the conference room at the local hotel but because she was unable to get the paychecks for the staff as promised the IDG team refused to participate in the IDG meeting and sign the updated comprehensive assessments. She stated that on 10/20/22, the owner had the bank cashiers checks to give to the staff as promised, that he was in a car accident and had another individual come in another car, get the bank cashiers check from the agency Owner to take to agency staff at the designated location for the IDG meeting. However, the individual in route to the designated location stopped at a local convenience store where his car was stolen along with the bank cashiers checks to pay the employees." On 10/28/22 at 6:15 p.m., the A/ADON was informed that an Immediate Jeopardy was identified related to Management Responsibility, Financial Solvency, Review of the Hospice Plan of Care, and Coordination of Care. On 11/03/22 at 12:42 p.m., the Administrator was notified an immediacy no longer existed as the agency discharged 23 patients. Immediate Action Taken: On October 26, 2022, at 10:00 a.m., the A/ADON of [Agencys Name Hospice A] met with the Owner to review the current situation. The A/ADON persuaded the Owner that we [Agencys Name] to continue to provide the best quality care for our patients [patients]we would have to transfer patients to other hospice agencies. This in turn would guarantee the continued quality of care to the patients [patients]. On 10/26/22, the A/ADON contacted another local [Hospice Agency B] to inquire if they [Hospice B] would be willing to admit/transfer patients of [Hospice Agency A] who choose to have the [Hospice Agency B] service their need. The [Hospice Agency B] agreed to admit/transfer any patients of [Hospi ce Agency A]. On 10/26/22 at 5:30 p.m., the A/ADON started calling patients/patients/families of Hospice Agency A to inform them that Hospice Agency A will assist them in finding a new hospice agency to provide their care; that they [Hospice A patient/patients] had a choice of hospice agencies, that Hospice A spoke with Hospice B and that Hospice B would be able to admit/transfer [Hospice As patient/patients]; that MSW and Chaplain services would be available for emergencies. The following list have a communication note entered in Hospice As ECR (electronic clinical record). (10/26/22) 5:57 p.m., Patient #2 was called and agreed to try Hospice B. 5:56 p.m., Patient #4 was called and agreed to try Hospice B. 6:00 p.m., Patient #5 was called...message left. 6:10 p.m., Patient #6 was called and agreed to try Hospice B. 6:15 p.m., Patient #7s family member (FM) was called and stated, you need to go see Patient #7, he will not answer the phone. 6:24 p.m., Patient #8 left message with FM/MPOA (medical power of attorney) 6:45 p.m., Patient #19 was called and agreed to try Hospice B. 6:50 p.m., Patient #1 was called and agreed to try Hospice B. 6:59 p.m., Patient #10 was called and agreed to try Hospice B. 7:06 p.m., Patient #11s FM was called stated that she will find another hospice agency...A/ADON informed Patient #11s FM that she would follow up on 10/27/22 or the next day. 7:13 p.m., Patient #13 was called and agreed to try Hospice B. 7:20 p.m., Patient #14 was called and agreed to try Hospice B. 7:27 p.m., Patient 15s FM was called and agreed to try Hospice B. 7:31 p.m., Patient #16s FM was called and agreed to try Hospice B. 7:39 p.m., Patient #18 was called and agreed to try Hospice B. 7:43 p.m., Patient 20 was called and agreed to try Hospice B. 7:50 p.m., Patient #21s FM was called and agreed to try Hospice B. 7:54 p.m., Patient #22s FM was called, and a message was left. 8:00 pm., Patient #23s FM was called, and a message was left. On 10/27/2022: 8:10 a.m., Patient #17s FM was seen in person and agreed to try Hospice B. 8:19 a.m., Patient #22s FM was called, and left message. 8:23 a.m., Patient #22s FM agreed to try Hospice B. 11:00 a.m., Patient #9s FM seen in person and will let A/ADON know their decision. 11:30 a.m., Patient #23s FM stated that there was a problem with communication did not understand the message...Patient #23s FM agreed to Hospice B coming to discuss their services with the patient. 12:31 p.m., Patient #8s FM called and stated he will let A/ADON know of decision. 12:52 p.m., Patient #18 was seen in person by the A/ADON and agreed to try Hospice B. 12:57 p.m., Patient #12s FM was called and agreed to try Hospice B. 1:14 p.m., Patient #3s FM was called and agreed to try Hospice B. 3:00 p.m., Patient #8s FM called and agreed to try Hospice B. 3:10 p.m., Patient #11s FM agreed to try Hospice B. On 10/28/22: Hospice C informed Hospice A that Patient #9 decided to go with them. Follow-up Action Taken: On 10/27/2022 the Letter of Agreement/ Contingency Plan was signed by Receiving Agency Hospice Bs Owner and Closing Agency Hospice A A/ADON. Hospice B transferred three patients on 10/27/2022. Hospice B transferred eleven patients on 10/28/2022. Hospice B is pending transfer of five patients on 10/31/2022. Hospice B is pending transfer of two patients on 11/01/2022. Patient #9s FM choose to go to Hospice C. October 31, 2022: Patient #8 transferred to Hospice B Patient #14 transferred to Hospice B Patient #18 transferred to Hospice B November 1, 2022: Patient #4s FM revoked (cancelled hospice services), declined assistance with services. Patient #6 transferred to Hospice B Patient #15 revoked hospice services, will place patient in skilled facility Patient #21 transferred to Hospice B. Patient #22 transferred to Hospice B Patient #23 transferred to Hospice B November 03, 2022: Patient #10 pending transfer on 11/03/2022 to Hospice B A/ADON will follow up with Hospice C on 10/31/2022. A/ADON will follow up with the following patients family: Patient #14, Patient #21, and Patient #5, on their choice of Hospice agencies 10/31/2022. Hospice A is planning on all patients in their care to be transferred or admitted to another hospice agency by 11/03/2022 Plan Going Forward: Hospice A will see that all patients are removed and transferred to another hospice agency. Hospice A will proceed with suspending license and/or closing agency. Hospice A Staff will be paid once CMS has made payments to Hospice A. Hospice As Clinical records and staff charts will remain with owner [Hospice As owner].

Based on record review and interview, the hospice interdisciplinary group (IDG) in collaboration with the individuals attending physician failed to review, revise, and document the individualized plan at least every 15 calendar days for nine of nine active patients (#1, #6, #9, #11, #12, #14, #16, #19 and #21) and one of one discharged patient (#24) records whose records were reviewed in that: Patients #1, #6, #9, #11, #12, #14, #16, #19 and #21 and #24 did not have signatures of the IDG team members and the attending physicians signature to demonstrate active and collaborative participation in the review of each patients POC to ensure that any changes in conditions were identified, discussed and coordinated among the IDG team members and the attending physician. This failure resulted in Patients #1, #6, #9, #11, #12, #14, #16, #19, #21 and #24s comprehensive assessment not being updated within the required timeframe by the IDG team members and the patients attending physician. This failure placed the agencys 23 active hospice patients at risk of receiving care that does not meet the patients current needs, dying without dignity and had the likelihood to cause serious harm, neglect and deterioration in the patients condition and would seriously impact the agencys 23 hospice patients and families. --- The findings included: Review of Patient #1's electronic clinical record (ECR) revealed a SOC date 04/22/22 with a terminal illness diagnosis of atherosclerotic heart disease, for the certification period of 09/16/22 to 11/16/22. Further review of Patient #1's ECR revealed the IDG met to review and revise the comprehensive assessments as follows: 09/24/22 and 10/05/22. Further review revealed no documented evidence that the IDG met to review and revise the patient's IDG/POC at least every 15 days. Review of Patient #6s ECR revealed a SOC date of 04/25/22 with a terminal illness diagnosis of Hypertensive Hear Disease with Chronic Kidney Disease, for the certification period of 10/03/22 to 12/01/22. Further review of Patient #6s ECR revealed the IDG met to review and revise the comprehensive assessments as follows: 10/05/22. Further review revealed no documented evidence that the IDG met to review and revise the patients comprehensive assessment at least every 15 days. Review of Patient #24s discharged ECR revealed a SOC date of 04/25/22 with a terminal illness diagnosis of Senile Degeneration of the Brain, for the certification period of 10/14/22 – 10/24/22. Further review of Patient #24s discharged ECR revealed the IDG met to review/revise the comprehensive assessment as follows: 10/05/22. Further review revealed no documented evidence that the IDG met to review/revise the patients IDG/POC at least every 15 days. Review of Patient #9s ECR revealed a SOC date of 04/27/22 with a terminal illness diagnosis of Cardiomegaly, for the certification period of 10/11/22 to 12/09/22. Further review of Patient #9s revealed that the IDG met to review/revise the comprehensive assessment on 10/05/22. Further review revealed no documented evidence that the IDG met to review/revise the patients IDG/POC at least every 15 days. Review of Patient #11s ECR revealed a SOC date of 04/21/22 with a terminal illness diagnosis of Senile Dementia of the Brain for the certification period of 08/30/22 to 10/28/22. Further review of Patient #11s ECR revealed the IDG met to review/revise the comprehensive assessment as follows: 09/09/22, 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to review/revise the patients IDG/POC at least every 15 days. Review of Patient 12s ECR revealed a SOC date of 09/14/22 with a terminal illness diagnosis of Senile Degeneration of the Brain, for the certification period of 09/14/22 to 11/12/22. Further review of Patient #12s ECR revealed the IDG met to review/revise the comprehensive assessment as follows: 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to review/revise the patients IDG/POC at least every 15 days. Review of Patient #14s ECR revealed a SOC date of 04/21/22 with a terminal illness diagnosis of Cirrhosis of the Liver, for certification period of 09/10/22 to 11/08/22. Further review of Patient #14s ECR revealed the IDG met to review/revise the comprehensive assessment as follows: 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to review/revise the patients IDG/POC at least every 15 days. Review of Patient #16s ECR revealed a SOC date of 08/21/22, with a terminal illness diagnosis of Senile Dementia of the Brain, for the certification period of 08/21/22 to 11/18/22. Further review of Patient #16s ECR revealed the IDG met to review/revise the comprehensive assessment as follows: 08/24/22, 09/07/22, 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to review/revise the patients IDG/POC at least every 15 days. Review of Patient #19s ECR revealed a SOC date pf 08/16/22, with a terminal illness diagnosis of Chronic Kidney Disease Stage 2 for the certification period of 08/16/22 to Further review of Patient #19s ECR revealed the IDG met to review/revise the comprehensive assessment as follows: 08/24/22, 09/07/22, 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to review/revise the patients IDG/POC at least every 15 days. Review of Patient #21s ECR revealed a SOC date of 04/25/22, with a terminal illness diagnosis of Chronic Obstructive Pulmonary Disease for the certification period of 10/08/22 to 12/03/22. Further review of Patient #21s ECR revealed the IDG met to review/revise the comprehensive assessment as follows: 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to review/revise the patients IDG/POC at least every 15 days. During an interview on 10/25/22 at 11:55 a.m., the Medical Director stated, ";that she is concerned for the agencys hospice patients and contacted the accrediting agency to seek guidance on the matter...that the Alternate Administrator/Director of Nurses (AA/DON) had resigned from the agency...that the Administrator/Alternate DON (A/ADON) is not answering calls or text messages and will only contact staff members to put out information and is not available to discuss issues/concerns regarding patient care." The Medical Director stated, that the IDG meeting was supposed to be held on 10/19/22 but was rescheduled for 10/20/22...The Medical Director stated that the IDG meeting was not held on 10/20/22...All IDG team members were present at the designated location for six hours and A/ADON was a no-show...Meeting was not held."...The Medical Director further stated ";that the A/ADON had to schedule the IDG team meeting at another location due to a restraining order filed by the owner of the building where the agency rents an office space; and added that both the Owner of the agency and the A/ADON are prohibited from entering the building." During an interview 11/02/22 at 10:20 a.m., the Administrator/ADON stated that IDG meetings are held every other Wednesday for all patients. She stated no, the agency did not conduct an ";actual" IDG meeting to update the patients comprehensive assessment as required during the week of 10/16/22. She stated that she did try to conduct an IDG meeting on 10/19/22 at 9:00 a.m., with the IDG team via ZOOM, which included the Medical Director, Chaplains E and F, the MSW, RN G, RN H and RN I. She stated that the IDG team refused to participate in the meeting unless, the Administrator/ADON had their paychecks (bank cashiers check). She stated that because she did not have their paychecks, and the IDG Meeting was rescheduled for 10/20/22 at a conference room located at a local hotel, and that she would participate via ZOOM; with the assurance that they would receive their paychecks. She stated that the IDG team met on 10/20/22 at the conference room at the local hotel but because she was unable to get the paychecks for the staff as promised the IDG team refused to participate in the IDG meeting and sign the updated comprehensive assessments. She stated that on 10/20/22, the owner had the bank cashiers checks to give to the staff as promised, that he was in a car accident and had another individual come in another car, get the bank cashiers check from the agency Owner to take to agency staff at the designated location for the IDG meeting. However, the individual in route to the designated location stopped at a local convenience store where his car was stolen along with the bank cashiers checks to pay the employees." On 10/28/22 at 6:15 p.m., the A/ADON was informed that an Immediate Jeopardy was identified related to Management Responsibility, Financial Solvency, Review of the Hospice Plan of Care, and Coordination of Care. On 11/03/22 at 12:42 p.m., the Administrator was notified the immediacy no longer existed as the agency discharged all 23 patients. Immediate Action Taken: On October 26, 2022, at 10:00 a.m., the A/ADON of [Agencys Name Hospice A] met with the Owner to review the current situation. The A/ADON persuaded the Owner that we [Agencys Name] to continue to provide the best quality care for our patients [patients]we would have to transfer patients to other hospice agencies. This in turn would guarantee the continued quality of care to the patients [patients]. On 10/26/22, the A/ADON contacted another local [Hospice Agency B] to inquire if they [Hospice B] would be willing to admit/transfer patients of [Hospice Agency A] who choose to have the [Hospice Agency B] service their need. The [Hospice Agency B] agreed to admit/transfer any patients of [Hospice Agency A]. On 10/26/22 at 5:30 p.m., the A/ADON started calling patients/patients/families of Hospice Agency A to inform them that Hospice Agency A will assist them in finding a new hospice agency to provide their care; that they [Hospice A patient/patients] had a choice of hospice agencies, that Hospice A spoke with Hospice B and that Hospice B would be able to admit/transfer [Hospice As patient/patients]; that MSW and Chaplain services would be available for emergencies. The following list have a communication note entered in Hospice As ECR (electronic clinical record). (10/26/22) 5:57 p.m., Patient #2 was called and agreed to try Hospice B. 5:56 p.m., Patient #4 was called and agreed to try Hospice B. 6:00 p.m., Patient #5 was called...message left. 6:10 p.m., Patient #6 was called and agreed to try Hospice B. 6:15 p.m., Patient #7s family member (FM) was called and stated, you need to go see Patient #7, he will not answer the phone. 6:24 p.m., Patient #8 left message with FM/MPOA (medical power of attorney) 6:45 p.m., Patient #19 was called and agreed to try Hospice B. 6:50 p.m., Patient #1 was called and agreed to try Hospice B. 6:59 p.m., Patient #10 was called and agreed to try Hospice B. 7:06 p.m., Patient #11s FM was called stated that she will find another hospice agency...A/ADON informed Patient #11s FM that she would follow up on 10/27/22 or the next day. 7:13 p.m., Patient #13 was called and agreed to try Hospice B. 7:20 p.m., Patient #14 was called and agreed to try Hospice B. 7:27 p.m., Patient 15s FM was called and agreed to try Hospice B. 7:31 p.m., Patient #16s FM was called and agreed to try Hospice B. 7:39 p.m., Patient #18 was called and agreed to try Hospice B. 7:43 p.m., Patient 20 was called and agreed to try Hospice B. 7:50 p.m., Patient #21s FM was called and agreed to try Hospice B. 7:54 p.m., Patient #22s FM was called, and a message was left. 8:00 pm., Patient #23s FM was called, and a message was left. On 10/27/2022: 8:10 a.m., Patient #17s FM was seen in person and agreed to try Hospice B. 8:19 a.m., Patient #22s FM was called, and left message. 8:23 a.m., Patient #22s FM agreed to try Hospice B. 11:00 a.m., Patient #9s FM seen in person and will let A/ADON know their decision. 11:30 a.m., Patient #23s FM stated that there was a problem with communication did not understand the message...Patient #23s FM agreed to Hospice B coming to discuss their services with the patient. 12:31 p.m., Patient #8s FM called and stated he will let A/ADON know of decision. 12:52 p.m., Patient #18 was seen in person by the A/ADON and agreed to try Hospice B. 12:57 p.m., Patient #12s FM was called and agreed to try Hospice B. 1:14 p.m., Patient #3s FM was called and agreed to try Hospice B. 3:00 p.m., Patient #8s FM called and agreed to try Hospice B. 3:10 p.m., Patient #11s FM agreed to try Hospice B. On 10/28/22: Hospice C informed Hospice A that Patient #9 decided to go with them. Follow-up Action Taken: On 10/27/2022 the Letter of Agreement/ Contingency Plan was signed by Receiving Agency Hospice Bs Owner and Closing Agency Hospice A A/ADON. Hospice B transferred three patients on 10/27/2022. Hospice B transferred eleven patients on 10/28/2022. Hospice B is pending transfer of five patients on 10/31/2022. Hospice B is pending transfer of two patients on 11/01/2022. Patient #9s FM choose to go to Hospice C. October 31, 2022: Patient #8 transferred to Hospice B Patient #14 transferred to Hospice B Patient #18 transferred to Hospice B November 1, 2022: Patient #4s FM revoked (cancelled hospice services), declined assistance with services. Patient #6 transferred to Hospice B Patient #15 revoked hospice services, will place patient in skilled facility Patient #21 transferred to Hospice B. Patient #22 transferred to Hospice B Patient #23 transferred to Hospice B November 03, 2022: Patient #10 pending transfer on 11/03/2022 to Hospice B A/ADON will follow up with Hospice C on 10/31/2022. A/ADON will follow up with the following patients family: Patient #14, Patient #21, and Patient #5, on their choice of Hospice agencies 10/31/2022. Hospice A is planning on all patients in their care to be transferred or admitted to another hospice agency by 11/03/2022 Plan Going Forward: Hospice A will see that all patients are removed and transferred to another hospice agency. Hospice A will proceed with suspending license and/or closing agency. Hospice A Staff will be paid once CMS has made payments to Hospice A. Hospice As Clinical records and staff charts will remain with owner [Hospice As owner].

Based on record reviews and interviews, the agency failed to maintain a system of communication and integration, in accordance with the hospices own written policies to ensure the ongoing sharing of information between all disciplines providing care and services for nine of nine active patients (#1, #6, #9, #11, #12, #14, #16, #19 and #21) and one of one discharged patient (#24) whose clinical records were reviewed. Patients #1, #6, #9, #11, #12, #14, #16, #19 and #21 and #24 did not have signatures of the IDG team members and the attending physicians signature to demonstrate active and collaborative participation in the review of each patients POC to ensure that any changes in conditions were identified, discussed, and coordinated among the IDG team members and the attending physician. This failure resulted in Patients #1, #6, #9, #11, #12, #14, #16, #19, #21 and #24s comprehensive assessment not being reviewed, discussed and coordinated among the IDG team members and the patients attending physician and/or Medical Director. This failure placed the agencys 23 active hospice patients at risk of receiving care that does not meet the patients current needs, dying without dignity and had the likelihood to cause serious harm, neglect and deterioration in the patients condition and would seriously impact the agencys 23 hospice patients and families. --- The findings included: Review of the agencys policy titled, ";PC.22 Coordination of Care" revised date 05/01/19, read in part, ";...IV. The IDG (interdisciplinary group) will maintain responsibility for directing, coordinating, and supervising the care and services provided by all medical entities...VI. The IDG will ensure that the care and services provided are based on all assessments of the patient and familys needs and are provided in accordance with the POC (plan of care) ...VII. All communication and coordination of care is documented in the clinical record." Review of Patient #1's electronic clinical record (ECR) revealed a SOC date 04/22/22 with a terminal illness diagnosis of atherosclerotic heart disease, for the certification period of 09/16/22 to 11/16/22. Further review of Patient #1's ECR revealed the IDG met to update the comprehensive assessments as follows: 09/24/22 and 10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #6s ECR revealed a SOC date of 04/25/22 with a terminal illness diagnosis of Hypertensive Hear Disease with Chronic Kidney Disease, for the certification period of 10/03/22 to 12/01/22. Further review of Patient #6s ECR revealed the IDG met to update the comprehensive assessments as follows: 10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #24s discharged ECR revealed a SOC date of 04/25/22 with a terminal illness diagnosis of Senile Degeneration of the Brain, for the certification period of 10/14/22 – 10/24/22. Further review of Patient #24s discharged ECR revealed the IDG met to update the comprehensive assessment as follows: 10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #9s ECR revealed a SOC date of 04/27/22 with a terminal illness diagnosis of Cardiomegaly, for the certification period of 10/11/22 to 12/09/22. Further review of Patient #9s revealed that the last updated comprehensive assessment was completed on 10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #11s ECR revealed a SOC date of 04/21/22 with a terminal illness diagnosis of Senile Dementia of the Brain for the certification period of 08/30/22 to 10/28/22. Further review of Patient #11s ECR revealed the IDG met to update the comprehensive assessment as follows: 09/09/22, 09/21/22 and 10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #12s ECR revealed a SOC date of 09/14/22 with a terminal illness diagnosis of Senile Degeneration of the Brain, for the certification period of 09/14/22 to 11/12/22. Further review of Patient #12s ECR revealed the IDG met to update the comprehensive assessment as follows: 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #14s ECR revealed a SOC date of 04/21/22 with a terminal illness diagnosis of Cirrhosis of the Liver, for certification period of 09/10/22 to 11/08/22. Further review of Patient #14s ECR revealed the IDG met to update the comprehensive assessment as follows: 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #16s ECR revealed a SOC date of 08/21/22, with a terminal illness diagnosis of Senile Dementia of the Brain, for the certification period of 08/21/22 to 11/18/22. Further review of Patient #16s ECR revealed the IDG met to update the comprehensive assessment as follows: 08/24/22, 09/07/22, 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #19s ECR revealed a SOC date pf 08/16/22, with a terminal illness diagnosis of Chronic Kidney Disease Stage 2 for the certification period of 08/16/22 to Further review of Patient #19s ECR revealed the IDG met to update the comprehensive assessment as follows: 08/24/22, 09/07/22, 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. Review of Patient #21s ECR revealed a SOC date of 04/25/22, with a terminal illness diagnosis of Chronic Obstructive Pulmonary Disease for the certification period of 10/08/22 to 12/03/22. Further review of Patient #21s ECR revealed the IDG met to update the comprehensive assessment as follows: 09/21/22 and10/05/22. Further review revealed no documented evidence that the IDG met to discuss any changes in the patient's condition and status to ensure that the patient receives the most effective care and treatment; and that the patient and familys needs are addressed. During an interview on 10/25/22 at 11:55 a.m., the Medical Director stated, ";that she is concerned for the agencys hospice patients and contacted the accrediting agency to seek guidance on the matter...that the Alternate Administrator/Director of Nurses (AA/DON) had resigned from the agency...that the Administrator/Alternate DON (A/ADON) is not answering calls or text messages and will only contact staff members to put out information and is not available to discuss issues/concerns regarding patient care." The Medical Director stated, that the IDG meeting was supposed to be held on 10/19/22 but was rescheduled for 10/20/22...The Medical Director stated that the IDG meeting was not held on 10/20/22...All IDG team members were present at the designated location for six hours and A/ADON was a no-show...Meeting was not held."...The Medical Director further stated ";that the A/ADON had to schedule the IDG team meeting at another location due to a restraining order filed by the owner of the building where the agency rents an office space; and added that both the Owner of the agency and the A/ADON are prohibited from entering the building." During an interview 11/02/22 at 10:20 a.m., the Administrator/ADON stated that IDG meetings are held every other Wednesday for all patients. She stated no, the agency did not conduct an ";actual" IDG meeting to update the patients comprehensive assessment as required during the week of 10/16/22. She stated that she did try to conduct an IDG meeting on 10/19/22 at 9:00 a.m., with the IDG team via ZOOM, which included the Medical Director, Chaplains E and F, the MSW, RN G, RN H and RN I. She stated that the IDG team refused to participate in the meeting unless, the Administrator/ADON had their paychecks (bank cashiers check). She stated that because she did not have their paychecks, and the IDG Meeting was rescheduled for 10/20/22 at a conference room located at a local hotel, and that she would participate via ZOOM; with the assurance that they would receive their paychecks. She stated that the IDG team met on 10/20/22 at the conference room at the local hotel but because she was unable to get the paychecks for the staff as promised the IDG team refused to participate in the IDG meeting and sign the updated comprehensive assessments. She stated that on 10/20/22, the owner had the bank cashiers checks to give to the staff as promised, that he was in a car accident and had another individual come in another car, get the bank cashiers check from the agency Owner to take to agency staff at the designated location for the IDG meeting. However, the individual in route to the designated location stopped at a local convenience store where his car was stolen along with the bank cashiers checks to pay the employees." On 10/28/22 at 6:15 p.m., the A/ADON was informed that an Immediate Jeopardy was identified related to Management Responsibility, Financial Solvency, Review of the Hospice Plan of Care, and Coordination of Care. On 11/03/22 at 12:42 p.m., the Administrator was notified an immediacy no longer existed as the agency discharged all 23 patients. Immediate Action Taken: On October 26, 2022, at 10:00 a.m., the A/ADON of [Agencys Name Hospice A] met with the Owner to review the current situation. The A/ADON persuaded the Owner that we [Agencys Name] to continue to provide the best quality care for our patients [patients]we would have to transfer patients to other hospice agencies. This in turn would guarantee the continued quality of care to the patients [patients]. The Owner also agreed to suspend Hospice Agency As license. On 10/26/22, the A/ADON contacted another local [Hospice Agency B] to inquire if they [Hospice B] would be willing to admit/transfer patients of [Hospice Agency A] who choose to have the [Hospice Agency B] service their need. The [Hospice Agency B] agreed to admit/transfer any patients of [Hospice Agency A]. On 10/26/22 at 5:30 p.m., the A/ADON started calling patients/patients/families of Hospice Agency A to inform them that Hospice Agency A will assist them in finding a new hospice agency to provide their care; that they [Hospice A patient/patients] had a choice of hospice agencies, that Hospice A spoke with Hospice B and that Hospice B would be able to admit/transfer [Hospice As patient/patients]; that MSW and Chaplain services would be available for emergencies. The following list have a communication note entered in Hospice As ECR (electronic clinical record). (10/26/22) 5:57 p.m., Patient #2 was called and agreed to try Hospice B. 5:56 p.m., Patient #4 was called and agreed to try Hospice B. 6:00 p.m., Patient #5 was called...message left. 6:10 p.m., Patient #6 was called and agreed to try Hospice B. 6:15 p.m., Patient #7s family member (FM) was called and stated, you need to go see Patient #7, he will not answer the phone. 6:24 p.m., Patient #8 left message with FM/MPOA (medical power of attorney) 6:45 p.m., Patient #19 was called and agreed to try Hospice B. 6:50 p.m., Patient #1 was called and agreed to try Hospice B. 6:59 p.m., Patient #10 was called and agreed to try Hospice B. 7:06 p.m., Patient #11s FM was called stated that she will find another hospice agency...A/ADON informed Patient #11s FM that she would follow up on 10/27/22 or the next day. 7:13 p.m., Patient #13 was called and agreed to try Hospice B. 7:20 p.m., Patient #14 was called and agreed to try Hospice B. 7:27 p.m., Patient 15s FM was called and agreed to try Hospice B. 7:31 p.m., Patient #16s FM was called and agreed to try Hospice B. 7:39 p.m., Patient #18 was called and agreed to try Hospice B. 7:43 p.m., Patient 20 was called and agreed to try Hospice B. 7:50 p.m., Patient #21s FM was called and agreed to try Hospice B. 7:54 p.m., Patient #22s FM was called, and a message was left. 8:00 pm., Patient #23s FM was called, and a message was left. On 10/27/2022: 8:10 a.m., Patient #17s FM was seen in person and agreed to try Hospice B. 8:19 a.m., Patient #22s FM was called, and left message. 8:23 a.m., Patient #22s FM agreed to try Hospice B. 11:00 a.m., Patient #9s FM seen in person and will let A/ADON know their decision. 11:30 a.m., Patient #23s FM stated that there was a problem with communication did not understand the message...Patient #23s FM agreed to Hospice B coming to discuss their services with the patient. 12:31 p.m., Patient #8s FM called and stated he will let A/ADON know of decision. 12:52 p.m., Patient #18 was seen in person by the A/ADON and agreed to try Hospice B. 12:57 p.m., Patient #12s FM was called and agreed to try Hospice B. 1:14 p.m., Patient #3s FM was called and agreed to try Hospice B. 3:00 p.m., Patient #8s FM called and agreed to try Hospice B. 3:10 p.m., Patient #11s FM agreed to try Hospice B. On 10/28/22: Hospice C informed Hospice A that Patient #9 decided to go with them. Follow-up Action Taken: On 10/27/2022 the Letter of Agreement/ Contingency Plan was signed by Receiving Agency Hospice Bs Owner and Closing Agency Hospice A A/ADON. Hospice B transferred three patients on 10/27/2022. Hospice B transferred eleven patients on 10/28/2022. Hospice B is pending transfer of five patients on 10/31/2022. Hospice B is pending transfer of two patients on 11/01/2022. Patient #9s FM choose to go to Hospice C. October 31, 2022: Patient #8 transferred to Hospice B Patient #14 transferred to Hospice B Patient #18 transferred to Hospice B November 1, 2022: Patient #4s FM revoked (cancelled hospice services), declined assistance with services. Patient #6 transferred to Hospice B Patient #15 revoked hospice services, will place patient in skilled facility Patient #21 transferred to Hospice B. Patient #22 transferred to Hospice B Patient #23 transferred to Hospice B November 03, 2022: Patient #10 pending transfer on 11/03/2022 to Hospice B A/ADON will follow up with Hospice C on 10/31/2022. A/ADON will follow up with the following patients family: Patient #14, Patient #21, and Patient #5, on their choice of Hospice agencies 10/31/2022. Hospice A is planning on all patients in their care to be transferred or admitted to another hospice agency by 11/03/2022 Plan Going Forward: Hospice A will see that all patients are removed and transferred to another hospice agency. Hospice A will proceed with suspending license and/or closing agency. Hospice A Staff will be paid once CMS has made payments to Hospice A. Hospice As Clinical records and staff charts will remain with owner [Hospice As owner].

The hospice must organize, manage, and administer its resources to provide the hospice care and services to patients, caregivers and families necessary for the palliation and management of the terminal illness and related conditions. --- The administrator failed to maintain sufficient funds and did not pay agency staff for two to three months. Refer to L0649

Based on record review and interviews, the administrator failed to manage its resource to provide care for management of terminal illness and related conditions in that: The agency failed to manage an effective budgeting and accounting system that promoted the health and safety of the agency's clients for the year 2022 and The administrator failed to maintain sufficient funds and did not pay agency staff for two to three months. --- The findings included: During an interview on 10/25/22 at 11:55 a.m., the Medical Director stated, ";that she is concerned for the agencys hospice patients and contacted the accrediting agency to seek guidance on the matter...that the Alternate Administrator/Director of Nurses (AA/DON) had resigned from the agency...that the Administrator/Alternate DON (A/ADON) is not answering calls or text messages and will only contact staff members to put out information and is not available to discuss issues/concerns regarding patient care." The Medical Director stated, that the IDG meeting was supposed to be held on 10/19/22 but was rescheduled for 10/20/22...The Medical Director stated that the IDG meeting was not held on 10/20/22...All IDG team members were present at the designated location for six hours and A/ADON was a no-show...Meeting was not held."...The Medical Director further stated ";that the A/ADON had to schedule the IDG team meeting at another location due to a restraining order filed by the owner of the building where the agency rents an office space; and added that both the Owner of the agency and the A/ADON are prohibited from entering the building." During an interview on 10/26/22 at 9:06 p.m., the Medical Director stated that she gets paid once a month. She denied accruing any bank fees for insufficient funds. She stated that when she went to the agencys bank to cash her paycheck dated 09/09/22 for August payment, she asked the bank representative if there were sufficient funds in the account for her to cash her check. She stated that the Bank Representative, stated that they could not disclose whether there were sufficient funds in the account, or if there was a problem...The Medical Director stated that she was check dated 09/30/22 which did not have a signature and was given a replacement check dated 10/03/22 but did not cash the check due to penalty charges she would be responsible for as stated by the bank representative for Financial Institution M. The Medical Director stated that she is still due to be paid 11/04/22. The Medical Director further stated, ";that she is still working for the agency, still writing orders for agency patients and working without pay." Review of checks provided by the Medical Director revealed the following: Financial Institution M: (Hospice Agency As Bank) 09/30/22, Check #: 1186 for $5,100.00 for payroll, did not have signature on check. 10/03/22, Check #1170 for $5,100.00 for payroll replacement check for Check # 1186 since it did not have a signature. The bank representative advised the Medical Director that if she chose to process the check [#1170] she [Medical Director] would be responsible for the penalty charges. During an interview on 10/26/22 at 12:33 p.m., Chaplain E stated that paychecks issued on 9/9/22 and 10/7/22 bounced (did not clear) and was charged fees for approximately $79.00. He stated that the owner wrote a cashiers check which he cashed at a ";Check Cashing Company" and was charged a $10.00 fee. He stated that his next paycheck is due 11/04/22. Review of paycheck from Financial Institution N revealed the following: (Hospice Agency As Bank) 10/07/22, Check #6006, written to Chaplain E for 1,766.31 (for 10/07/22). Review of a Chaplain Es personal banking statement from 10/14/22 to 10/18/22 revealed the following fees were assessed to Chaplain Es personal checking account...10/18/22 (NSF) non-sufficient funds fee: $32.50...10/14/22 Charge Back Fee $15.00." During an interview on 10/26/22 at 1:21 p.m., RN I stated, ";that paychecks dated 09/23/22 and 10/7/22 bounced (did not clear) ...that she has a caseload of eight-nine patients and occasionally does on-call...RN I further stated...that she cant make visits (patient visits) out of money...last visit made 10/14/22." Review of payroll check from Financial Institution M (Hospice Agency As Bank) revealed the following: 09/23/22, Check #1167 written to RN I for $2,326.30 (for 09/23/22) Review of payroll from Financial Institution N (Hospice Agency As Bank) revealed the following: 10/07/22, Check #6008, written to RN I for 2,556.30 (for 10/07/22) 10/07/22, Check #6010, written to RN I for $2,331.30 (replacement for 09/23/22) Review of a letter dated 10/18/22 addressed to the agency from RN Is personal bank account read in part, ";...Regarding Fees Assessed to Account: the following fees were assessed to our members [RN I] checking account...10/18/22 (NSF) non-sufficient funds fee: $32.50...10/14/22 Charge Back Fee $15.00." During an interview on 10/26/22 at 1:37 p.m., MSW D stated that she is due five weeks pay and the paycheck dated 10/7/22 bounced (did not clear). During an interview on 10/26/22 at 1:58 p.m., RN Case Manager G stated that she has not been paid for last two pay periods 10/7/22 and 10/21/22 because there was a hold placed on Hospice Agency As bank account due to issues with previous checks. She stated that she was issued a paycheck dated 09/23/22 which bounced (did not clear) and was issued another check from the owner dated 10/07/22 which also bounced (did not clear). RN G further stated that she has not been paid since 10/21/22. During an interview on 10/26/22 at 3:34 p.m. the following statements were made by the following agency staff: Office Manager stated, ";After she gets paid... ";I probably wont stay with the agency." Chaplain E stated, ";When I get paid, the owner and management will have to change in order for me [Chaplain E] to stay." RN G stated, ";After I get paid...would stay...care about my patients." Chaplain/Bereavement Coordinator F stated, ";Management and Corporate would need major changes if I am going to stay, but no, I wouldnt" During an interview on 10/31/22 at 4:13 p.m., the Administrator/Alternate Director of Nurses (A/ADON) stated that all Staff are paid every other Friday and that the Medical Director is paid the first pay period of the month. The A/ADON stated that the agency is behind two months August/September with not paying the staff and medical director. During the same interview, the Surveyor asked the A/ADON to provide the billing statements/records for the last three months and the copies of the returned paychecks. The A/ADON stated that she did not have access to the billing records and was not able to provide that information. During an interview on 11/01/22 at 10:54 a.m., the Office Manager stated that she gets paid every other Friday and has not been paid since October 7, 2022. She stated that she is owed two pay checks 10/21/22 and 11/4/22 and does not believe she will be paid. During the same interview, the Surveyor asked the Office Manager if she could provide any copies of bank statements and/or billing statements for the past three months and copies of paychecks that cleared or did not clear. The Office Manager stated that she did not have access to copies of banking and or billing statements but provided a copy of a letter addressed to the Owner from Financial Institution L (FI-L), a ";Returned Check Notice" dated 10/13/22 from Financial Institution O addressed to the former Alternate Administrator/Director of Nurses (AA/DON), the resignation letter from the former AA/DON, and copies of paychecks that did not clear. Review of the letter of resignation for AA/DON dated 10/09/22 provided to the Surveyor on 11/01/22 at approximately 10:54 a.m. by the Office Manager read in part, ";...ever since 09/09/22, the payroll check situation has been very stressful...You (A/AADON) advised me not to cash my check (09/13/22)...the check was signed by an unauthorized person at Financial Institution L...I received a cashiers check from the Owner dated 09/13/22 from Financial Institution M which did not include my on-call pay...and on 09/23/22 I received a personal check from the Owner from his account at Financial Institution M...which I could not cash until Saturday because there were no funds to cover the check...Then on 10/07/22 I received another check from Financial Institution N still did not include my on-call pay for September...I had to go to a ";Check Cash It" and was charged $87.00 in fees...This has caused me migraines and distress and for this I am resigning effective today 10/09/22." Review of paychecks from Financial Institution N: 10/07/22 paid to AA/DON for $2,125.00 Review of ";Returned Check Notice" dated 10/13/22 from Financial Institution O (AA/DONs personal bank account) ...revealed, records indicated that a check for $2,125.00 was cashed or deposited and was returned unpaid... and the account was charged...Further review revealed that AA/DONs personal account is subject to be offset and/or restricted and closed if not paid within 45 days." 10/07/22 paid to AA/DON for $2,874.11 Receipt dated 10/08/22 for $87.21 for cashing fee for check dated 10/07/22 for paycheck for $2,874. 00. Review of letter from Financial Institution L (FI – L) dated 09/13/22 from the Financial Center Manager addressed to the Owner, read in part, ";Based on our (FI-L) for the recent unusual activity which we have detected in your checking accounts (Hospice Agency As Bank), we are no longer comfortable with your maintaining a relationship at FI-L. Please discontinue writing checks at these accounts...We (FI-L) ask that you close your accounts by September 19, 2022." Review of paycheck from Financial Institution N revealed the following: 10/07/22 Check # 6002 written to Office Manager for $1,358.27. Review of the agencys policy titled, ";LD.5 Responsibilities of the Administrator" revised date, 12/01/2019, read in part, ";I. The agency defines the responsibilities of the Administrator to include, but not be limited to: Implementing an effective budgeting and accounting system that promotes the health and safety of agency patients...FF. Monitoring business operations to ensure financial stability." Review of the agencys policy titled, ";LD.10 Financial Plan and Solvency", revised date 02/01/20, read in part, ";II. A. the agency will have the financial ability to carry out its functions. B. The agency will not knowingly pay employees with checks from accounts with insufficient funds...C. The agency will have sufficient funds to meet its payroll...D. The agency will make available upon request, to the State, financial records relating to its ability to carry out its functions." On 10/28/22 at 6:15 p.m., the A/ADON was informed that an Immediate Jeopardy was identified related to Management Responsibility, Financial Solvency, Review of the Hospice Plan of Care and Coordination of Care. On 11/3/2022 @ 12:42 pm was notified an immediacy no longer existed as the agency did not have any more patients. Immediate Action Taken: On October 26, 2022, at 10:00 a.m., the A/ADON of [Agencys Name Hospice A] met with the Owner to review the current situation. The A/ADON persuaded the Owner that we [Agencys Name] to continue to provide the best quality care for our patients [patients]we would have to transfer patients to other hospice agencies. This in turn would guarantee the continued quality of care to the patients. On 10/26/22, the A/ADON contacted another local [Hospice Agency B] to inquire if they [Hospice B] would be willing to admit/transfer patients of [Hospice Agency A] who choose to have the [Hospice Agency B] service their need. The [Hospice Agency B] agreed to admit/transfer any patients of [Hospice Agency A]. On 10/26/22 at 5:30 p.m., the A/ADON started calling patients/families of Hospice Agency A to inform them that Hospice Agency A will assist them in finding a new hospice agency to provide their care; that they [Hospice A patient] had a choice of hospice agencies, that Hospice A spoke with Hospice B and that Hospice B would be able to admit/transfer [Hospice As patient]; that MSW and Chaplain services would be available for emergencies. The following list have a communication note entered in Hospice As ECR (electronic clinical record). (10/26/22) 5:57 p.m., Patient #2 was called and agreed to try Hospice B. 5:56 p.m., Patient #4 was called and agreed to try Hospice B. 6:00 p.m., Patient #5 was called...message left. 6:10 p.m., Patient #6 was called and agreed to try Hospice B. 6:15 p.m., Patient #7s family member (FM) was called and stated, you need to go see Patient #7, he will not answer the phone. 6:24 p.m., Patient #8 left message with FM/MPOA (medical power of attorney) 6:45 p.m., Patient #19 was called and agreed to try Hospice B. 6:50 p.m., Patient #1 was called and agreed to try Hospice B. 6:59 p.m., Patient #10 was called and agreed to try Hospice B. 7:06 p.m., Patient #11s FM was called stated that she will find another hospice agency...A/ADON informed Patient #11s FM that she would follow up on 10/27/22 or the next day. 7:13 p.m., Patient #13 was called and agreed to try Hospice B. 7:20 p.m., Patient #14 was called and agreed to try Hospice B. 7:27 p.m., Patient 15s FM was called and agreed to try Hospice B. 7:31 p.m., Patient #16s FM was called and agreed to try Hospice B. 7:39 p.m., Patient #18 was called and agreed to try Hospice B. 7:43 p.m., Patient 20 was called and agreed to try Hospice B. 7:50 p.m., Patient #21s FM was called and agreed to try Hospice B. 7:54 p.m., Patient #22s FM was called, and a message was left. 8:00 pm., Patient #23s FM was called, and a message was left. On 10/27/2022: 8:10 a.m., Patient #17s FM was seen in person and agreed to try Hospice B. 8:19 a.m., Patient #22s FM was called, and left message. 8:23 a.m., Patient #22s FM agreed to try Hospice B. 11:00 a.m., Patient #9s FM seen in person and will let A/ADON know their decision. 11:30 a.m., Patient #23s FM stated that there was a problem with communication did not understand the message...Patient #23s FM agreed to Hospice B coming to discuss their services with the patient. 12:31 p.m., Patient #8s FM called and stated he will let A/ADON know of decision. 12:52 p.m., Patient #18 was seen in person by the A/ADON and agreed to try Hospice B. 12:57 p.m., Patient #12s FM was called and agreed to try Hospice B. 1:14 p.m., Patient #3s FM was called and agreed to try Hospice B. 3:00 p.m., Patient #8s FM called and agreed to try Hospice B. 3:10 p.m., Patient #11s FM agreed to try Hospice B. On 10/28/22: Hospice C informed Hospice A that Patient #9 decided to go with them. Follow-up Action Taken: On 10/27/2022 the Letter of Agreement/ Contingency Plan was signed by Receiving Agency Hospice Bs Owner and Closing Agency Hospice A A/ADON. Hospice B transferred three patients on 10/27/2022. Hospice B transferred eleven patients on 10/28/2022. Hospice B is pending transfer of five patients on 10/31/2022. Hospice B is pending transfer of two patients on 11/01/2022. Patient #9s FM choose to go to Hospice C. October 31, 2022: Patient #8 transferred to Hospice B Patient #14 transferred to Hospice B Patient #18 transferred to Hospice B November 1, 2022: Patient #4s FM revoked (cancelled hospice services), declined assistance with services. Patient #6 transferred to Hospice B Patient #15 revoked hospice services, will place patient in skilled facility Patient #21 transferred to Hospice B. Patient #22 transferred to Hospice B Patient #23 transferred to Hospice B November 03, 2022: Patient #10 pending transfer on 11/03/2022 to Hospice B A/ADON will follow up with Hospice C on 10/31/2022. A/ADON will follow up with the following patients family: Patient #14, Patient #21, and Patient #5, on their choice of Hospice agencies 10/31/2022. Hospice A is planning on all patients in their care to be transferred or admitted to another hospice agency by 11/03/2022 Plan Going Forward: Hospice A will see that all patients are removed and transferred to another hospice agency and will plan with suspending license and/or closing agency. Hospice A Staff will be paid once CMS has made payments to Hospice A. Hospice As Clinical records and staff charts will remain with owner [Hospice As owner]. On 11/3/2022 @ 12:42 p.m. the Administrator was notified an immediacy no longer existed as the agency discharged all 23 patients. During an interview on 10/25/22 at 11:55 a.m., the Medical Director stated, ";that she is concerned for the agencys hospice patients and contacted the accrediting agency to seek guidance on the matter...that the Alternate Administrator/Director of Nurses (AA/DON) had resigned from the agency...that the Administrator/Alternate DON (A/ADON) is not answering calls or text messages and will only contact staff members to put out information and is not available to discuss issues/concerns regarding patient care." The Medical Director stated, that the IDG meeting was supposed to be held on 10/19/22 but was rescheduled for 10/20/22...The Medical Director stated that the IDG meeting was not held on 10/20/22...All IDG team members were present at the designated location for six hours and A/ADON was a no-show...Meeting was not held."...The Medical Director further stated ";that the A/ADON had to schedule the IDG team meeting at another location due to a restraining order filed by the owner of the building where the agency rents an office space; and added that both the Owner of the agency and the A/ADON are prohibited from entering the building." During an interview on 10/26/22 at 9:06 p.m., the Medical Director stated that she gets paid once a month. She denied accruing any bank fees for insufficient funds. She stated that when she went to the agencys bank to cash her paycheck dated 09/09/22 for August payment, she asked the bank representative if there were sufficient funds in the account for her to cash her check. She stated that the Bank Representative, stated that they could not disclose whether there were sufficient funds in the account, or if there was a problem...The Medical Director stated that she was check dated 09/30/22 which did not have a signature and was given a replacement check dated 10/03/22 but did not cash the check due to penalty charges she would be responsible for as stated by the bank representative for Financial Institution M. The Medical Director stated that she is still due to be paid 11/04/22. The Medical Director further stated, ";that she is still working for the agency, still writing orders for agency patients and working without pay." Review of checks provided by the Medical Director revealed the following: Financial Institution M: (Hospice Agency As Bank) 09/30/22, Check #: 1186 for $5,100.00 for payroll, did not have signature on check. 10/03/22, Check #1170 for $5,100.00 for payroll replacement check for Check # 1186 since it did not have a signature. The bank representative advised the Medical Director that if she chose to process the check [#1170] she [Medical Director] would be responsible for the penalty charges. During an interview on 10/26/22 at 12:33 p.m., Chaplain E stated that paychecks issued on 9/9/22 and 10/7/22 bounced (did not clear) and was charged fees for approximately $79.00. He stated that the owner wrote a cashiers check which he cashed at a ";Check Cashing Company" and was charged a $10.00 fee. He stated that his next paycheck is due 11/04/22. Review of paycheck from Financial Institution N revealed the following: (Hospice Agency As Bank) 10/07/22, Check #6006, written to Chaplain E for 1,766.31 (for 10/07/22). Review of a Chaplain Es personal banking statement from 10/14/22 to 10/18/22 revealed the following fees were assessed to Chaplain Es personal checking account...10/18/22 (NSF) non-sufficient funds fee: $32.50...10/14/22 Charge Back Fee $15.00." During an interview on 10/26/22 at 1:21 p.m., RN I stated, ";that paychecks dated 09/23/22 and 10/7/22 bounced (did not clear) ...that she has a caseload of eight-nine patients and occasionally does on-call...RN I further stated...that she cant make visits (patient visits) out of money...last visit made 10/14/22." Review of payroll check from Financial Institution M (Hospice Agency As Bank) revealed the following: 09/23/22, Check #1167 written to RN I for $2,326.30 (for 09/23/22) Review of payroll from Financial Institution N (Hospice Agency As Bank) revealed the following: 10/07/22, Check #6008, written to RN I for 2,556.30 (for 10/07/22) 10/07/22, Check #6010, written to RN I for $2,331.30 (replacement for 09/23/22) Review of a letter dated 10/18/22 addressed to the agency from RN Is personal bank account read in part, ";...Regarding Fees Assessed to Account: the following fees were assessed to our members [RN I] checking account...10/18/22 (NSF) non-sufficient funds fee: $32.50...10/14/22 Charge Back Fee $15.00." During an interview on 10/26/22 at 1:37 p.m., MSW D stated that she is due five weeks pay and the paycheck dated 10/7/22 bounced (did not clear). During an interview on 10/26/22 at 1:58 p.m., RN Case Manager G stated that she has not been paid for last two pay periods 10/7/22 and 10/21/22 because there was a hold placed on Hospice Agency As bank account due to issues with previous checks. She stated that she was issued a paycheck dated 09/23/22 which bounced (did not clear) and was issued another check from the owner dated 10/07/22 which also bounced (did not clear). RN G further stated that she has not been paid since 10/21/22. During an interview on 10/26/22 at 3:34 p.m. the following statements were made by the following agency staff: Office Manager stated, ";After she gets paid... ";I probably wont stay with the agency." Chaplain E stated, ";When I get paid, the owner and management will have to change in order for me [Chaplain E] to stay." RN G stated, ";After I get paid...would stay...care about my patients." Chaplain/Bereavement Coordinator F stated, ";Management and Corporate would need major changes if I am going to stay, but no, I wouldnt" During an interview on 10/31/22 at 4:13 p.m., the Administrator/Alternate Director of Nurses (A/ADON) stated that all Staff are paid every other Friday and that the Medical Director is paid the first pay period of the month. The A/ADON stated that the agency is behind two months August/September with not paying the staff and medical director. During the same interview, the Surveyor asked the A/ADON to provide the billing statements/records for the last three months and the copies of the returned paychecks. The A/ADON stated that she did not have access to the billing records and was not able to provide that information. During an interview on 11/01/22 at 10:54 a.m., the Office Manager stated that she gets paid every other Friday and has not been paid since October 7, 2022. She stated that she is owed two pay checks 10/21/22 and 11/4/22 and does not believe she will be paid. During the same interview, the Surveyor asked the Office Manager if she could provide any copies of bank statements and/or billing statements for the past three months and copies of paychecks that cleared or did not clear. The Office Manager stated that she did not have access to copies of banking and or billing statements but provided a copy of a letter addressed to the Owner from Financial Institution L (FI-L), a ";Returned Check Notice" dated 10/13/22 from Financial Institution O addressed to the former Alternate Administrator/Director of Nurses (AA/DON), the resignation letter from the former AA/DON, and copies of paychecks that did not clear. Review of the letter of resignation for AA/DON dated 10/09/22 provided to the Surveyor on 11/01/22 at approximately 10:54 a.m. by the Office Manager read in part, ";...ever since 09/09/22, the payroll check situation has been very stressful...You (A/AADON) advised me not to cash my check (09/13/22)...the check was signed by an unauthorized person at Financial Institution L...I received a cashiers check from the Owner dated 09/13/22 from Financial Institution M which did not include my on-call pay...and on 09/23/22 I received a personal check from the Owner from his account at Financial Institution M...which I could not cash until Saturday because there were no funds to cover the check...Then on 10/07/22 I received another check from Financial Institution N still did not include my on-call pay for September...I had to go to a ";Check Cash It" and was charged $87.00 in fees...This has caused me migraines and distress and for this I am resigning effective today 10/09/22." Review of paychecks from Financial Institution N: 10/07/22 paid to AA/DON for $2,125.00 Review of ";Returned Check Notice" dated 10/13/22 from Financial Institution O (AA/DONs personal bank account) ...revealed, records indicated that a check for $2,125.00 was cashed or deposited and was returned unpaid... and the account was charged...Further review revealed that AA/DONs personal account is subject to be offset and/or restricted and closed if not paid within 45 days." 10/07/22 paid to AA/DON for $2,874.11 Receipt dated 10/08/22 for $87.21 for cashing fee for check dated 10/07/22 for paycheck for $2,874. 00. Review of letter from Financial Institution L (FI – L) dated 09/13/22 from the Financial Center Manager addressed to the Owner, read in part, ";Based on our (FI-L) for the recent unusual activity which we have detected in your checking accounts (Hospice Agency As Bank), we are no longer comfortable with your maintaining a relationship at FI-L. Please discontinue writing checks at these accounts...We (FI-L) ask that you close your accounts by September 19, 2022." Review of paycheck from Financial Institution N revealed the following: 10/07/22 Check # 6002 written to Office Manager for $1,358.27. Review of the agencys policy titled, ";LD.5 Responsibilities of the Administrator" revised date, 12/01/2019, read in part, ";I. The agency defines the responsibilities of the Administrator to include, but not be limited to: Implementing an effective budgeting and accounting system that promotes the health and safety of agency patients...FF. Monitoring business operations to ensure financial stability." Review of the agencys policy titled, ";LD.10 Financial Plan and Solvency", revised date 02/01/20, read in part, ";II. A. the agency will have the financial ability to carry out its functions. B. The agency will not knowingly pay employees with checks from accounts with insufficient funds...C. The agency will have sufficient funds to meet its payroll...D. The agency will make available upon request, to the State, financial records relating to its ability to carry out its functions." On 10/28/22 at 6:15 p.m., the A/ADON was informed that an Immediate Jeopardy was identified related to Management Responsibility, Financial Solvency, Review of the Hospice Plan of Care and Coordination of Care. On 11/3/2022 @ 12:42 pm was notified an immediacy no longer existed as the agency did not have any more patients. Immediate Action Taken: On October 26, 2022, at 10:00 a.m., the A/ADON of [Agencys Name Hospice A] met with the Owner to review the current situation. The A/ADON persuaded the Owner that we [Agencys Name] to continue to provide the best quality care for our patients [patients]we would have to transfer patients to other hospice agencies. This in turn would guarantee the continued quality of care to the patients. The Owner also agreed to suspend Hospice Agency As license. On 10/26/22, the A/ADON contacted another local [Hospice Agency B] to inquire if they [Hospice B] would be willing to admit/transfer patients of [Hospice Agency A] who choose to have the [Hospice Agency B] service their need. The [Hospice Agency B] agreed to admit/transfer any patients of [Hospice Agency A]. On 10/26/22 at 5:30 p.m., the A/ADON started calling patients/families of Hospice Agency A to inform them that Hospice Agency A will assist them in finding a new hospice agency to provide their care; that they [Hospice A patient] had a choice of hospice agencies, that Hospice A spoke with Hospice B and that Hospice B would be able to admit/transfer [Hospice As patient]; that MSW and Chaplain services would be available for emergencies. The following list have a communication note entered in Hospice As ECR (electronic clinical record). (10/26/22) 5:57 p.m., Patient #2 was called and agreed to try Hospice B. 5:56 p.m., Patient #4 was called and agreed to try Hospice B. 6:00 p.m., Patient #5 was called...message left. 6:10 p.m., Patient #6 was called and agreed to try Hospice B. 6:15 p.m., Patient #7s family member (FM) was called and stated, you need to go see Patient #7, he will not answer the phone. 6:24 p.m., Patient #8 left message with FM/MPOA (medical power of attorney) 6:45 p.m., Patient #19 was called and agreed to try Hospice B. 6:50 p.m., Patient #1 was called and agreed to try Hospice B. 6:59 p.m., Patient #10 was called and agreed to try Hospice B. 7:06 p.m., Patient #11s FM was called stated that she will find another hospice agency...A/ADON informed Patient #11s FM that she would follow up on 10/27/22 or the next day. 7:13 p.m., Patient #13 was called and agreed to try Hospice B. 7:20 p.m., Patient #14 was called and agreed to try Hospice B. 7:27 p.m., Patient 15s FM was called and agreed to try Hospice B. 7:31 p.m., Patient #16s FM was called and agreed to try Hospice B. 7:39 p.m., Patient #18 was called and agreed to try Hospice B. 7:43 p.m., Patient 20 was called and agreed to try Hospice B. 7:50 p.m., Patient #21s FM was called and agreed to try Hospice B. 7:54 p.m., Patient #22s FM was called, and a message was left. 8:00 pm., Patient #23s FM was called, and a message was left. On 10/27/2022: 8:10 a.m., Patient #17s FM was seen in person and agreed to try Hospice B. 8:19 a.m., Patient #22s FM was called, and left message. 8:23 a.m., Patient #22s FM agreed to try Hospice B. 11:00 a.m., Patient #9s FM seen in person and will let A/ADON know their decision. 11:30 a.m., Patient #23s FM stated that there was a problem with communication did not understand the message...Patient #23s FM agreed to Hospice B coming to discuss their services with the patient. 12:31 p.m., Patient #8s FM called and stated he will let A/ADON know of decision. 12:52 p.m., Patient #18 was seen in person by the A/ADON and agreed to try Hospice B. 12:57 p.m., Patient #12s FM was called and agreed to try Hospice B. 1:14 p.m., Patient #3s FM was called and agreed to try Hospice B. 3:00 p.m., Patient #8s FM called and agreed to try Hospice B. 3:10 p.m., Patient #11s FM agreed to try Hospice B. On 10/28/22: Hospice C informed Hospice A that Patient #9 decided to go with them. Follow-up Action Taken: On 10/27/2022 the Letter of Agreement/ Contingency Plan was signed by Receiving Agency Hospice Bs Owner and Closing Agency Hospice A A/ADON. Hospice B transferred three patients on 10/27/2022. Hospice B transferred eleven patients on 10/28/2022. Hospice B is pending transfer of five patients on 10/31/2022. Hospice B is pending transfer of two patients on 11/01/2022. Patient #9s FM choose to go to Hospice C. October 31, 2022: Patient #8 transferred to Hospice B Patient #14 transferred to Hospice B Patient #18 transferred to Hospice B November 1, 2022: Patient #4s FM revoked (cancelled hospice services), declined assistance with services. Patient #6 transferred to Hospice B Patient #15 revoked hospice services, will place patient in skilled facility Patient #21 transferred to Hospice B. Patient #22 transferred to Hospice B Patient #23 transferred to Hospice B November 03, 2022: Patient #10 pending transfer on 11/03/2022 to Hospice B A/ADON will follow up with Hospice C on 10/31/2022. A/ADON will follow up with the following patients family: Patient #14, Patient #21, and Patient #5, on their choice of Hospice agencies 10/31/2022. Hospice A is planning on all patients in their care to be transferred or admitted to another hospice agency by 11/03/2022 Plan Going Forward: Hospice A will see that all patients are removed and transferred to another hospice agency and will proceed with suspending license and/or closing agency. Hospice A Staff will be paid once CMS has made payments to Hospice A. Hospice As Clinical records and staff charts will remain with owner [Hospice As owner]. On 11/3/2022 @ 12:42 p.m. the Administrator was notified an immediacy no longer existed as the agency discharged all 23 patients.