Every finding on record at Comprehensive Hospice Services, LLC

This CONDITION is NOT MET as evidence by: Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Initial and Comprehensive Assessment of Patients was met as follows: 1.The Hospice Agency (HA) failed to conduct a comprehensive assessment to identify the patient health status, care, and services needs related to terminal illness, for two of seven sampled patients (Patient 19 and Patient 22). For Patient 19, the HA did not conduct an assessment for Patient 19's peritoneal dialysis (PD - a treatment for kidney failure that uses lining of the abdomen or belly to filter blood, remove toxins and excess fluid in the body) access (a flexible, hollow plastic tube that's surgically placed in lower abdomen) to identify patient's need for necessary PD care. For Patient 22 with Tuberculosis (TB – infectious bacterial disease in the tissue, especially in the lungs) the HA did not assess the patient's need for further care and services to manage the patient's TB. This deficient practice resulted in the HA not identifying the patient's care need and has a potential for the patient's PD access and TB status not being managed that could lead to complication from PD and spread of TB infection. (Refer to L524). 2.The Hospice Agency (HA) failed to ensure the patient's medications listed in the patient's medication profile were accurate and updated, for two of seven sampled patients (Patient 17 and Patient 18). This deficient practice had the potential for adverse effect on the patient health condition when the medications are not administered timely and as ordered, which can affect the health and safety of the patients. (Refer to L530). 3. The Hospice Agency (HA) failed to conduct an initial bereavement (a period of time characterized by grief or mourning after the loss of loved one) assessment for six of seven sampled patients (Patient 4, Patient 17, Patient 19, Patient 20, Patient 21, and Patient 22). This deficient practice had the potential to impact a family members' abilities to cope with the patients' death. (Refer to L531). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated Federal compliance to ensure safety and the highest quality care and services were provided to the patients certified to receive hospice care and benefits. --- -

Based on interview and record review the Hospice Agency (HA) failed to conduct and complete an assessment to identifies the patient's immediate care and services need for two of seven sampled patients (Patient 19 and 22). For Patient 19, has peritoneal dialysis (PD - a treatment for kidney failure that uses lining of the abdomen or belly to filter blood, remove toxins and excess fluid in the body) access (a flexible, hollow plastic tube that's surgically placed in lower abdomen), did not assess for PD care. For Patient 22, with Tuberculosis (TB – infectious bacterial disease in the tissue, especially in the lungs.) did not assess for further care and services needs. This deficient practice resulted in the hospice agency's inability to provide quality of patient care and other services affecting the patients' health status and wellbeing. --- Findings: a. A review of Patient 19s ";Personal Information" indicated P19 was admitted on 9/27/2022 with a terminal diagnosis of supraventricular tachycardia (rapid heart rate) and secondary diagnosis of end stage renal disease (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A telephone interview on 3/7/2023, at 1:05 p.m., with Patient 19s care giver (CG4) and the assistance of Translation Services, operator #17762 (TS-17762), Patient 19s CG4 stated, ";he needs long term care, not hospice care." CG4 also stated that Patient 19 sees his primary physician once a week to check his PD. CG4 stated, she assists the patient perform PD daily. A record review of Patient 19s Electronic Medical Record (EMR), the EMR did not indicate the skilled nurse (SN) assessed Patient 19s PD. A record review of Patient 19s ";Visit Note RN (Registered Nurse)" dated 2/26/2023, 2/13/2023, 1/30/2023, and 1/16/2023, did not indicate RN1 assessed Patient 19s PD. b. A review of Patient 22s ";Personal Information" indicated Patient 22 was admitted on 10/11/2022 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD- breathing / air flow problems). A record review Patient 22s ";Comprehensive Nursing Assessment" dated 10/11/2023 indicated ";none" under section ";Immunological/Infection". It also indicated ";Patient has a Tuberculosis with productive cough and thick white sputum" under ";Narrative and Disease Trajectory" section. A record review of Patient 22s Electronic Medical Record (EMR), the EMR indicated there was one comprehensive assessment dated 10/11/2022 under ";History of Nursing Assessment". A record review of Patient 22s ";Certification of Terminal Illness (CTI)" dated 10/11/2022 to 1/8/2023 indicated under the ";RN (Registered Nurse) Prognosis Summary" – ";Patient has a Tuberculosis with productive cough and thick white sputum." A record review of Patient 22s ";Current Treatment/Medication DME List" indicated Patient 22 was prescribed three different medications for tuberculosis on 10/11/2022: Pyridoxine, Rifampin, and Isoniazid one tablet once a day. There is no stop date documented. A record review of Patient 22s ";Visit Note RN (Registered Nurse)" dated 2/21/2023, 2/7/2023, and 1/24/2023, did not indicate RN1 assessed Patient 22s TB. The notes also indicated ";none" under section ";Immunological/Infection". A concurrent interview and record review on 3/6/2023 at 2 p.m. with the Administrator (ADM) of Patient 22s Electronic Medical Record (EMR), the ADM stated that a nursing reassessment has not been completed, the last one was documented on 10/11/2022. ADM stated that Patient 22, ";definitely has a respiratory issue but unable to confirm if it is due to TB or not. A concurrent interview and record review on 3/6/2023 at 2:30 p.m. with the Administrator (ADM) of Patient 22s EMR, the ADM stated, after looking into Patient 22s EMR, ";There is nothing mentioned if it is current or being treated or a new finding. I dont know, there is nothing documented." A home visit was scheduled on 3/7/2023 for Patient 22 but was cancelled due to unknown TB status. A concurrent interview and record review on 3/8/2023 at 11:41 a.m. with the ADM of Patient 22s EMR, the ADM stated, ";The nursing initial assessment was accurate but incomplete. They didnt specify about the TB. Need to do a head-to-toe assessment, especially communicable diseases and she is on 3 different TB meds. We are exposing every other person if its an active TB, what are we doing." A review of the Hospice Agency (HA) Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 3/2/23, indicated, ";L0522 ...A review and audit of patient files was made for corrections and updated to ensure compliance."

Based on interview and record review the Hospice Agency (HA) failed to conduct a comprehensive assessment to identify the patient health status, care, and services needs related to terminal illness, for two of seven sampled patients (Patient 19 and Patient 22). For Patient 19, the HA did not conduct an assessment for Patient 19's peritoneal dialysis (PD - a treatment for kidney failure that uses lining of the abdomen or belly to filter blood, remove toxins and excess fluid in the body) access (a flexible, hollow plastic tube that's surgically placed in lower abdomen) to identify patient's need for necessary PD care. For Patient 22 with Tuberculosis (TB – infectious bacterial disease in the tissue, especially in the lungs) the HA did not assess the patient's need for further care and services to manage the patient's TB. This deficient practice resulted in the HA not identifying the patient's care need and has a potential for the patient's PD access and TB status not being managed that could lead to complication from PD and spread of TB infection. --- Findings: a. A review of Patient 19s ";Personal Information" indicated P19 was admitted on 9/27/2022 with a terminal diagnosis of supraventricular tachycardia (rapid heart rate) and secondary diagnosis of end stage renal disease (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A record review of Patient 19s ";Visit Note RN (Registered Nurse)" dated 2/26/2023, 2/13/2023, 1/30/2023, and 1/16/2023, did not indicate RN1 assessed Patient 19s PD. A telephone interview on 3/7/2023 at 1:05 p.m. with Patient 19s care giver (CG4) and the assistance of Translation Services, operator #17762 (TS-17762), Patient 19s CG4 stated, ";he needs long term care, not hospice care." CG4 also stated that Patient 19, visit the primary physician in the clinic once a week to check his PD. CG4 stated, she assisted the patient for daily PD care. A review of Patient 19s ";POC/IDG (Plan of Care/Interdisciplinary group) Review" dated 3/1/2023, 2/15/2023, 2/1/2023, and 1/18/2023, indicated License Vocational Nurse (LVN) visit frequency were once per week and as needed. Registered Nurse (RN) once every two weeks and one as needed visit. Interventions under Integumentary/Skin included: monitor skin integrity every visit and report any signs and symptoms (S/S) of skin breakdown such as redness, irritations, abrasions, and excoriations. The notes did not identify or addressed Patient 19s PD access. There was no documentation on assessment and care of the patient's PD b. A review of Patient 22s ";Personal Information" indicated Patient 22 was admitted on 10/11/2022 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD- breathing / air flow problems). A record review Patient 22s ";Comprehensive Nursing Assessment" dated 10/11/2023 indicated ";none" under section ";Immunological/Infection". It also indicated ";Patient has a Tuberculosis with productive cough and thick white sputum" under ";Narrative and Disease Trajectory" section. A review of Patient 22s Electronic Medical Record (EMR), the EMR indicated there was one comprehensive assessment dated 10/11/2022 under ";History of Nursing Assessment". A review of Patient 22s ";Certification of Terminal Illness (CTI)" dated 10/11/2022 to 1/8/2023 indicated under the ";Registered Nurse (RN) Prognosis Summary" – ";Patient has a Tuberculosis with productive cough and thick white sputum." A record review of Patient 22s ";Current Treatment/Medication DME List" indicated Patient 22 was prescribed three different medications for tuberculosis on 10/11/2022: Pyridoxine (a form of vitamin B6 used as a dietary supplement), Rifampin (a medication used to prevent and treat tuberculosis and other bacterial infections), and Isoniazid (an antibiotic used to treat latent (resting or non growing) TB) one tablet once a day. There was no stop date documented. A review of Patient 22s ";POC/IDG (Plan of Care/Interdisciplinary group) Review" dated 3/1/2023, 2/15/2023, 2/1/2023, and 1/18/2023, indicated SN (skilled nurse) visit frequency were once per week and as needed for symptom management. The notes also indicated the review consist of one problem area – Pain. Interventions included: assess and monitor pain and severity every visit; assess and report non-verbal pain based on body language, moaning, restlessness; check pain status; and instruct family/PCG to give pain medications when pain level is greater than 4. Therapy reviewed by IDG team. The notes did not identify or addressed Patient 22s TB status. There was no documentation of the status of the patient's TB. A concurrent interview and record review on 3/6/2023 at 2 p.m. with the Administrator (ADM) of Patient 22s Electronic Medical Record (EMR), the ADM stated, ";nothing about TB". ADM also stated that Patient 22, ";definitely has a respiratory issue", but unable to confirm if it was due to TB or not. A concurrent interview and record review on 3/8/2023 at 11:41 a.m. with the ADM of Patient 22s POC/IDG in the EMR, the ADM stated, ";There is no mention of TB on any of her IDGs, SOC 10/11/2022." A review of the Hospice Agency (HA) Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 3/2/23, indicated, ";L0524 ... A review and audit of patient files was made for corrections and updated to ensure compliance."

Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure the medications listed in the patient's medication profile were updated, for two of seven sampled patients (Patient 17 and Patient 18). This deficient practice had the potential for adverse effect on the patient health condition when the medications are not administered timely and as ordered, which can affect the health and safety of the patients. --- a). A review of Patient 17s clinical record indicated, 17 was admitted on 10/11/22, with diagnoses of acute ischemic heart disease (heart weakening caused by reduced blood flow to the heart). During an observation of the home visit, on 3/7/23, at 10:25 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed providing care to Patient 17. LVN 1 was observed asking Patient 17 to bring out the bottles of medications she was taking. P17 was observed stating to LVN 1 she did not have medications with her and had left them at her sisters home. Patient 17 was observed stating to LVN 1 she did not know the name of the medications, but knew she was taking three medications. A review of Patient 17s clinical record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, indicated the following medications: ";Lisinopril (to treat high blood pressure) 20 mg (milligram, unit of measurement) ... Amlodipine (to treat high blood pressure) 5 mg... Docusate Sodium (stool softener) 100 mg... Levsin (to treat excessive secretions) 0.125 mg/ml (milliliter, unit of measurement) drops... Bisacodyl (laxative, to treat constipation)10 mg... Acetaminophen (pain/fever reducer) 650 mg... Lorazepam (to treat anxiety) 2mg/ml... Morphine Sulfate (to treat severe pain) 20 mg... Prochlorperazine (to treat nausea or vomiting) 25 mg..." b). A review of Patient 18s clinical record indicated, the patient was admitted on 11/17/22, with diagnoses including chronic obstructive pulmonary disease (COPD – a group of disease that cause difficulty breathing). During an observation of the home visit, on 3/7/23, at 9:40 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed providing care to Patient 18. LVN 1 was observed reviewing the medication bottles of the patient. During a concurrent interview and record review on 3/7/23, at 9:42 a.m., Patient 18s ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 and the medications of Patient 18 available at home. LVN 1 stated Patient 18 medication Lorazepam (used to relieve anxiety) label on the bottle indicated to take the medication at bedtime as needed, but not indicated on the patient medication list to take the medication at bedtime as needed. During a concurrent interview and record review on 3/7/23, at 9:45 a.m., Patient 18s record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 while reviewing medications P18 was taking at home. LVN 1 stated the following medications Patient 18 reported taking but where not in the record: Levothyroxine (to treat low thyroid) 25 mcg (micrograms, unit of measurement) 1 tablet by mouth in the morning on empty stomach. Methocarbamol (for muscle spasms) 500 mg 1 tablet by mouth at bedtime. Medication was prescribed 11/19/22. During a concurrent interview and record review on 3/7/23, at 10:07 a.m., Patient 18s record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 while reviewing medications Patient 18 was taking at home. LVN 1 stated Patient 18 had duplicate medications at home of the following: Acetaminophen (fever reducer/treat mild pain) 650 mg rectal suppository. Prochlorperazine 25 mg rectal suppository, Lorazepam 2mg/ml concentrated solution. During a concurrent interview and record review on 3/7/23, at 10:09 a.m., P18s record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 while reviewing medications Patient 18 was taking at home. LVN 1 stated medication Morphine Sulfate, as listed in the record, was not in the patients home. Patient 18 stated she did not have Morphine Sulfate because she took it and ran out. Patient 18 stated the last time she took Morphine Sulfate was 2 weeks ago. During a concurrent interview and record review on 3/7/23, at 10:15 a.m., Patient 18s record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 while reviewing medications Patient 18 was taking at home. LVN 1 stated Atropine (to treat excessive secretions) 1% was not listed in the record. LVN 1 stated the packaging indicated eye drops, but the label indicated to take 2 drops under the tongue every 4 hours as needed for excessive secretions. Patient 18 stated she last used Atropine a week ago to treat dry and pain in the eyes. During a concurrent interview and record review on 3/7/23, at 10:20 a.m., Patient 18 s record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 while reviewing medications P18 was taking at home. LVN 1 stated there was no medication listed for the nebulizer. P18 stated she had not used the nebulizer because there was no medication for it. During an interview on 3/7/23, at 11:20 a.m., LVN 1 stated Patient 18s medications were all over the place and there were a lot of discrepancies. During an interview on 3/8/23, at 12:07 p.m., the administrator (ADM) stated it was important to educate the patient regarding medications because they need to know how to take the medications, side effects, duration, how often they should take it. The ADM stated Atropine is a medication that should be used at the end of life to decrease secretions because patients who are dying produce a lot of saliva and have a difficult time swallowing. When the ADM was informed Patient 18 was taking Atropine in her eyes, the ADM stated the nurses were not providing education and should be reviewing the medications the patients are taking every visit. The ADM stated if Patient 18 continues to take Atropine for her eyes, for long term, she will have dry eyes, and this will cause eye irritation. A review of the Hospice Agency (HA) Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 3/2/23, indicated, ";L0530 ... A review and audit of patient files was made for corrections and updated to ensure compliance."

Based on interview and record review the Hospice Agency (HA) failed to conduct an initial bereavement (a period of lime characterized by grief or mourning after the loss of loved one) assessment for six of seven sampled patients (Patient 4, Patient 17, Patient 19, Patient 20, Patient 21, and Patient 22). This deficient practice had the potential to impact a family members' abilities to cope with the patients' death. --- Findings: a). A review of Patient 4s clinical record indicated, the patient was admitted on 6/1/22, with diagnosis of heart failure (a chronic condition in which the heart doesnt pump blood as well as it should). During an interview on 3/8/23, at 11:31 a.m., the administrator (ADM) stated Patient 4 did not have an initial bereavement assessment done. The ADM stated there should have been an initial bereavement assessment done. b. A review of Patient 17s clinical record indicated, the patient was admitted on 10/11/22, with diagnoses of acute ischemic heart disease (heart weakening caused by reduced blood flow to the heart). During an interview on 3/8/23, at 11:22 a.m., the administrator (ADM) stated Patient 17 did not have an initial bereavement assessment done. The ADM stated it was important to have an initial bereavement assessment done to evaluate the mental health of the patient. The ADM stated if bereavement assessments are not done it means the HA is not providing what patients are being told, values, standards, on what CMS (Centers for Medicaid Services) says HA should be providing. During an interview on 3/8/23, at 11:23 a.m., the administrator (ADM) stated Patient 17 did not have an initial bereavement assessment done. c. A review of Patient 19s ";Personal Information" indicated Patient 19 was admitted on 9/27/2022 with a terminal diagnosis of supraventricular tachycardia (rapid heart rate) and secondary diagnosis of end stage renal disease (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of Patient 19s ";POC/IDG (Plan of Care/Interdisciplinary group) Review" dated 3/1/2023, 2/15/2023, 2/1/2023, and 1/18/2023, indicated the goal of bereavement is for ";patient/family will have an understanding of the bereavement services offered by hospice within 1 to 5 days. Patient/family will utilize available emotional, social, and spiritual resources in the next 2 to 4 weeks." It also indicates the status is ";controlled". A concurrent interview and record review on 3/8/2023 at 11:23 a.m. with the Administrator (ADM) of Patient 19's Electronic Medical Record (EMR), the ADM stated, ";Doesnt look like there is a bereavement assessment, wasnt done because he declined MSW (medical social worker). Services are offered by the SOC (start of care) nurse." d. A review of Patient 20s ";Personal Information" indicated Patient 20 was admitted on 8/4/2022 and discharged on 1/11/2023 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD- breathing / air flow problems). A concurrent interview and record review on 3/8/2023 at 11:32 a.m. with the Administrator (ADM) of P20s Electronic Medical Record (EMR), the ADM stated that Patient 20 had a start of care (SOC) date of 8/4/2022 and that his bereavement assessment was completed on 9/16/2022. e. A review of Patient 21s ";Personal Information" indicated P21 was admitted on 11/17/2022 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD- breathing / air flow problems). A review of Patient 21s ";POC/IDG (Plan of Care/Interdisciplinary group) Review" dated 3/1/2023, 2/15/2023, 2/10/2023, 2/1/2023, and 1/18/2023, indicated the goal of bereavement is for ";patient/family will have an understanding of the bereavement services offered by hospice within 1 to 5 days. Patient/family will utilize available emotional, social, and spiritual resources in the next 2 to 4 weeks." It also indicates the status is ";controlled". A concurrent interview and record review on 3/8/2023 at 11:26 a.m. with the Administrator (ADM) of Patient 21s Electronic Medical Record (EMR), the ADM stated, ";No initial bereavement assessment. No initial psychosocial assessment. There is nothing written that the patient declined MSW. There is no order for MSW." f. A review of Patient 22s ";Personal Information" indicated Patient 22 was admitted on 10/11/2022 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD- breathing / air flow problems). A review of Patient 22s ";POC/IDG (Plan of Care/Interdisciplinary group) Review" dated 3/1/2023, 2/15/2023, 2/1/2023, and 1/18/2023, indicated there is a total of one issue with Patient 22, ";pain". A concurrent interview and record review on 3/8/2023 at 11:30 a.m. with the Administrator (ADM) of Patient 22s Electronic Medical Record (EMR), the ADM stated, ";No initial bereavement assessment." An interview on 3/8/2023, at 11:35 a.m., with the ADM, the ADM stated, ";Initial bereavement assessment should be done within 5 days of SOC. If patient agrees to be seen by SC (spiritual counselor) and MSW. If patient refuses to be seen by SC or MSW the initial bereavement is not done. Psychosocial assessment, your mental health plays a huge role in your physical health. We need to know if the patient lives in a safe environment. What are the family dynamics. Does the patient have all the basic needs if there any neglect or abuse. If it does not happen, it is not standard care we are not providing what we are saying we are providing." A review of the Hospice Agency (HA) Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 3/2/23, indicated, ";L0531 ... A review and audit of patient files was made for corrections and updated to ensure initial bereavement is completed to ensure compliance."

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) met and updated the comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospices patients well-being, comfort and dignity throughout the dying process) at least every 15 days for six of seven sampled patients (Patient 4, Patient 17, Patient 18, Patient 19, Patient 21, and Patient 22). This deficient practice resulted in the IDG team not updating the comprehensive assessment to ensure all the needs were met. --- Findings: a. A review of Patient 4s clinical record indicated, the patient was admitted on 6/1/22, with diagnosis of heart failure (a chronic condition in which the heart doesnt pump blood as well as it should). During an interview on 3/6/23 at 11:30 a.m., the Administrator (ADM) stated members of the IDG group at minimum included the doctor, medical social worker (MSW), registered nurse, and chaplain. The ADM stated the doctor, social worker, chaplain, and registered nurse needed to participate in the IDG group meetings and validate their input by reviewing the notes entered and signing the patient record to validate their attendance and their input. A review of Patient 4s clinical record titled, ";POC/IDG Review", dated 1/19/23, did not indicate the doctor and MSW attended the meeting. The record indicated ";IDG Discussion/Updated Comprehensive Assessment Review Nursing: SN (skilled nurse) to continue home visit per frequency as ordered. Continue with plan of care. Spiritual: The Chaplain will continue to provide spiritual and emotional support according to the Patients plan of care. Psychosocial:" no notes documented, ";Other/Physician:" no notes documented. A review of Patient 4s clinical record titled, ";POC/IDG Review", dated 1/25/23, did not indicate the doctor and MSW attended the meeting. The record indicated, ";IDG Discussion/Updated Comprehensive Assessment Review, Nursing..." Over the course of 4 months, the patients health progressively declined...The patient will continue to be provided with reasonable and necessary services for the palliation and management of the terminal illness..." A review of Patient 4s clinical record titled, ";POC/IDG Review", dated 2/1/23, did not indicate the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. The record indicated, IDG discussion/Updated Comprehensive Assessment Review, Nursing: Continue with plan of care. Spiritual: The Chaplain will continue to provide spiritual and emotional support according to the Patients plan of care. Further review of the record did not indicate the IDG group discussed a plan of discharge. A review of Patient 4s clinical record titled, ";POC/IDG Review", dated 2/15/23, did not indicate the doctor, MSW, and Registered Nurse updated the comprehensive assessment. There was no signature of their attendance. The record indicated, ";IDG Discussion/Updated Comprehensive Assessment Review, nursing: Continue with plan of care. Spiritual: Patient discharged." b. A review of Patient 17s clinical record indicated, the patient was admitted on 10/11/22, with diagnoses of acute ischemic heart disease (heart weakening caused by reduced blood flow to the heart). A review of Patient 17s record titled, ";POC/IDG Review", dated 1/18/23, did not indicated the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. A review of Patient 17s record titled, ";POC/IDG Review", dated 2/1/23, did not indicated the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. A review of Patient 17s record titled, ";POC/IDG Review", dated 2/15/23, did not indicated the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. A review of Patient 17s record titled, ";POC/IDG Review", dated 3/1/23, did not indicated the doctor, MSW and Chaplain updated the comprehensive assessment. There was no signature of their attendance. c. A review of Patient 18s clinical record indicated, the patient was admitted on 11/17/22, with diagnoses including chronic obstructive pulmonary disease (COPD). During an observation of the home visit, on 3/7/23, at 9:40 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed providing care to Patient 18. LVN 1 was observed reviewing the medication bottles presented to the nurse by Patient 18. During a concurrent interview and record review on 3/7/23, at 9:45 a.m., Patient 18s record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 while reviewing medications Patient 18 was taking at home. LVN 1 stated the following medications Patient 18 reported taking but where not in the record: Levothyroxine (to treat low thyroid) 25 mcg (micrograms, unit of measurement) 1 tablet by mouth in the morning on empty stomach. Methocarbamol (for muscle spasms) 500 mg 1 tablet by mouth at bedtime. Medication was prescribed 11/19/22. During a concurrent interview and record review on 3/7/23, at 10:07 a.m., Patient 18s record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 while reviewing medications Patient 18 was taking at home. LVN 1 stated P18 had duplicate medications at home of the following: Acetaminophen (fever reducer/treat mild pain) 650 mg rectal suppository Prochlorperazine 25 mg rectal suppository, Lorazepam 2mg/ml concentrated solution. During a concurrent interview and record review on 3/7/23, at 10:09 a.m., Patient 18s record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 while reviewing medications P18 was taking at home. LVN 1 stated medication Morphine Sulfate, as listed in the record, was not in the patients home. Patient 18 stated she did not have Morphine Sulfate because she took it and ran out. Patient 18 stated the last time she took Morphine Sulfate was 2 weeks ago. During a concurrent interview and record review on 3/7/23, at 10:15 a.m., Patient 18s record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 while reviewing medications Patient 18 was taking at home. LVN 1 stated Atropine (to treat excessive secretions) 1% was not listed in the record. LVN 1 stated the packaging indicated eye drops, but the label indicated to take 2 drops under the tongue every 4 hours as needed for excessive secretions. Patient 18 stated she last used Atropine a week ago to treat dry and pain in the eyes. During a concurrent interview and record review on 3/7/23, at 10:20 a.m., Patient 18s record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 while reviewing medications Patient 18 was taking at home. LVN 1 stated there was no medication listed for the nebulizer. Patient 18 stated she had not used the nebulizer because there was no medication for it. During an interview on 3/7/23, at 11:20 a.m., LVN 1 stated Patient 18s medications were all over the place and there were a lot of discrepancies. A review of Patient 18s clinical record titled, ";POC/IDG Review", dated 1/18/23, did not indicate the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. Further review of the record did not indicate the IDG group discussed Patient 18s medication regime and need to educate about taking medications as ordered. A review of Patient 18s clinical record titled, ";POC/IDG Review", dated 2/1/23, did not indicate the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. Further review of the record did not indicate the IDG group discussed Patient 18s medication regime and need to educate about taking medications as ordered. A review of Patient 18s clinical record titled, ";POC/IDG Review", dated 2/15/23, did not indicate the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. Further review of the record did not indicate the IDG group discussed Patient 18s medication regime and need to educate about taking medications as ordered. A review of Patient 18s clinical record titled, ";POC/IDG Review", dated 3/1/23, did not indicate the doctor, MSW, and Chaplain updated the comprehensive assessment. There was no signature of their attendance. Further review of the record did not indicate the IDG group discussed Patient 18s medication regime and need to educate about taking medications as ordered. d. A review of Patient 19s ";Personal Information" indicated Patient 19 was admitted on 9/27/2022 with a terminal diagnosis of supraventricular tachycardia (rapid heart rate) and secondary diagnosis of end stage renal disease (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During an interview on 3/6/23, at 1:45 p.m., the ADM stated she did not know if Patient 19 was on peritoneal dialysis because the IDGs did not mention to it. The ADM stated she did not know if the dialysis was continued or discontinued. The ADM stated there should be a mention of Patient 19s peritoneal dialysis because it is a big thing. The ADM stated the nurses needed a lot of education. The ADM stated it was important to include peritoneal dialysis in the plan of care because the care team needs to know if Patient 19 is having any issues with it such as congestive heart failure and cellulitis (skin infection). A review of Patient 19s clinical record titled, ";POC/IDG Review", dated 1/18/23, did not indicate the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. Further review of the record did not indicate the IDG group discussed Patient 19s PD access. A review of Patient 19s clinical record titled, ";POC/IDG Review", dated 2/1/23, did not indicate the doctor, chaplain, and MSW updated the comprehensive assessment. There was no signature of their attendance. Further review of the record did not indicate the IDG group discussed Patient 19s PD access. A review of Patient 19s clinical record titled, ";POC/IDG Review", dated 2/15/23, did not indicate the doctor, and MSW updated the comprehensive assessment. There was no signature of their attendance. Further review of the record did not indicate the IDG group discussed Patient 19s PD access. A review of Patient 19s clinical record titled, ";POC/IDG Review", dated 3/1/23, did not indicate the doctor, chaplain, and MSW updated the comprehensive assessment. There was no signature of their attendance. Further review of the record did not indicate the IDG group discussed Patient 19s PD access. e. A review of Patient 21s ";Personal Information" indicated P21 was admitted on 11/17/2022 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD- breathing / air flow problems). A review of Patient 21s clinical record titled, ";POC/IDG Review", dated 1/18/23, did not indicate the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. A review of Patient 21s clinical record titled, ";POC/IDG Review", dated 1/18/23, did not indicate the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. A review of Patient 21s clinical record titled, ";POC/IDG Review", dated 2/1/23, did not indicate the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. A review of Patient 21s clinical record titled, ";POC/IDG Review", dated 2/10/23, did not indicate the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. A review of Patient 21s clinical record titled, ";POC/IDG Review", dated 2/15/23, did not indicate the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. A review of Patient 21s clinical record titled, ";POC/IDG Review", dated 3/1/23, did not indicate the doctor, MSW, and Chaplain updated the comprehensive assessment. There was no signature of their attendance. f. A review of Patient 22s ";Personal Information" indicated Patient 22 was admitted on 10/11/2022 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD- breathing / air flow problems). A record review Patient 22s ";Comprehensive Nursing Assessment" dated 10/11/2023 indicated ";none" under section ";Immunological/Infection". It also indicated ";Patient has a Tuberculosis with productive cough and thick white sputum" under ";Narrative and Disease Trajectory" section. A review of Patient 22s clinical record titled, ";POC/IDG Review", dated 1/18/23, did not indicate the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. Further review of the record did not indicate the IDG addressed Patient 22s Tuberculosis. A review of Patient 22s clinical record titled, ";POC/IDG Review", dated 2/1/23, did not indicate the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. Further review of the record did not indicate the IDG addressed Patient 22's Tuberculosis. A review of Patient 22s clinical record titled, ";POC/IDG Review", dated 2/15/23, did not indicate the doctor and MSW updated the comprehensive assessment. There was no signature of their attendance. Further review of the record did not indicate the IDG addressed Patient 22s Tuberculosis. A review of Patient 22s clinical record titled, ";POC/IDG Review", dated 3/1/23, did not indicate the doctor, MSW, and Chaplain updated the comprehensive assessment. There was no signature of their attendance. Further review of the record did not indicate the IDG addressed Patient 22s Tuberculosis. An interview on 3/8/2023, at 10:20 a.m., with the ADM, the ADM stated, ";Either the discipline or the transcriber can fill out the summary section of the IDG. The discipline will check the transcriptions and make edits if needed and sign. Anytime you sign anything is validated." A telephone interview on 3/8/2023, at 1:06 p.m., with the Administrator Designee (AD), the AD stated that the disciplines should have their authenticated signatures on the IDG...

Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG), in consultation with the patient's physician prepared the written plan of care (POC – an individualized guide for the needs and services supplied to patient and their care givers/family facing a terminal illness.) for two of seven sampled patients (Patient19 and Patient 22). Patient 19s POC did not address his peritoneal dialysis (PD) access (a catheter that is flexible, hollow tube about the size of a straw that's surgically placed in lower abdomen. A small piece of tubing is left outside of the body that can be covered when not in use) on his right abdominal area. Patient 22s POC did not address his Tuberculosis (TB – infectious bacterial disease in the tissue, especially in the lungs) status. This deficient practice had the potential to result in preventing the patients from reaching their care planning goals. --- Findings: a. A review of Patient 19s ";Personal Information" indicated Patient 19 was admitted on 9/27/2022 with a terminal diagnosis of supraventricular tachycardia (rapid heart rate) and secondary diagnosis of end stage renal disease (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A telephone interview on 3/7/2023, at 1:05 p.m., with Patient 19s wife/care giver (CG4) and the assistance of Translation Services, operator #17762 (TS-17762), Patient 19s CG4 stated, ";he needs long term care, not hospice care." CG4 also stated that Patient 19 sees his doctor once a week to check his PD. Wife also stated that she assists the patient perform PD daily. A review of Patient 19s ";POC/IDG (Plan of Care/Interdisciplinary group) Review" dated 3/1/2023, 2/15/2023, 2/1/2023, and 1/18/2023, indicated LVN (license vocational nurse) visit frequency were once per week and as needed. RN (Registered Nurse) once every two weeks and one as needed visit. Interventions under Integumentary/Skin included: monitor skin integrity every visit and report any signs and symptoms (S/S) of skin breakdown such as redness, irritations, abrasions, and excoriations ( wearing off the skin). The notes did not identify or addressed Patient 19s PD access. A review of Patient 19s ";POC (Plan of Care) Summary" indicated there was no mention of Patient 19s PD access. b. A review of Patient 22s ";Personal Information" indicated Patient 22 was admitted on 10/11/2022 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD- breathing / air flow problems). A record review Patient 22s ";Comprehensive Nursing Assessment" dated 10/11/2023 indicated ";none" under section ";Immunological/Infection". It also indicated ";Patient has a Tuberculosis with productive cough and thick white sputum" under ";Narrative and Disease Trajectory" section. A record review of Patient 22s Electronic Medical Record (EMR), the EMR indicated there was one comprehensive assessment dated 10/11/2022 under ";History of Nursing Assessment". A record review of Patient 22s ";Certification of Terminal Illness (CTI)" dated 10/11/2022 to 1/8/2023 indicated under the ";RN (Registered Nurse) Prognosis Summary" – ";Patient has a Tuberculosis with productive cough and thick white sputum." A record review of Patient 22s ";Current Treatment/Medication DME List" indicated Patient 22 was prescribed three different medications for tuberculosis on 10/11/2022: Pyridoxine, Rifampin, and Isoniazid one tablet once a day. There is no stop date documented. A review of Patient 22s ";POC/IDG (Plan of Care/Interdisciplinary group) Review" dated 3/1/2023, 2/15/2023, 2/1/2023, and 1/18/2023, indicated SN (skilled nurse) visit frequency were once per week and as needed for symptom management. The notes also indicated Patient 22s TB status was not identified or addressed. A review of Patient 22s ";POC (Plan of Care) Summary" indicated there was no mention of Patient 22s TB status. A concurrent interview and record review on 3/6/2023 at 2 p.m. with the Administrator (ADM) of Patient 22s Electronic Medical Record (EMR), the ADM stated, ";nothing about TB". A concurrent interview and record review on 3/8/2023 at 11:41 a.m. with the ADM of Patient 22s POC in the EMR, the ADM stated, ";There is nothing mention of TB, no precautions or isolation. I dont see any mention." A review of the Hospice Agency (HA) Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 3/2/23, indicated, ";L0537 ... A review and audit of patient files was made for corrections and updated to ensure compliance." 1.The Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG), in consultation with the patient's physician prepared the written plan of care (POC – an individualized guide for the needs and services supplied to patient and their care givers/family facing a terminal illness.) for two of seven sampled patients (Patient19 and Patient 22). Patient 19s POC did not address his peritoneal dialysis access (a catheter that is flexible, hollow tube about the size of a straw that's surgically placed in lower abdomen. A small piece of tubing is left outside of the body that can be covered when not in use) on his right abdominal area. Patient 22s POC did not address his Tuberculosis (TB – infectious bacterial disease in the tissue, especially in the lungs) status. There was no evidence the physician was consulted in the development of the plan of care. This deficient practice had the potential to result in preventing the patients from reaching their care planning goals. (Refer to L537). 2.The Hospice Agency (HA) staff failed to provide care and services by not conducting weekly home visits by the licensed nurses as indicated in the patient's Plan of Care (POC - an individualized guide for the needs and services supplied to patient and their care givers/family facing a terminal illness) for five of seven sampled patients (Patient 17, Patient 18, Patient 19, Patient 21, and Patient 22). This deficient practice had the potential for not meeting the patient needs that were identified in the POC that could impact the patients health status and well-being. (Refer to L543). 3. The Hospice Agency (HA) failed to educate one of seven sampled patients (Patient 18) regarding the comfort kit (small supply of medications kept at home available to rapidly treat symptoms that occur with terminal illness). This deficient practice resulted in the patient using medication incorrectly, placing the patient at risk of long-term complications. (Refer to L544). 4. The Hospice Agency (HA) failed to ensure one of seven sampled patients (Patient 17) had the medical equipment necessary to manage a patient's symptoms at home as indicated in the patient's Plan of Care (POC - an individualized guide for the needs and services supplied to patient and their care givers/family facing a terminal illness). Patient 17 was not provided at home an oxygen concentrator (medical device that gives extra oxygen) as ordered by the physician. This deficient practice had the potential for the patient not receiving oxygen as needed for respiratory difficulty and had the potential to result in respiratory distress. (Refer to L550). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated federal compliance to ensure the highest quality of care and services are provided to the patients under their care.

Based on interview and record review the Hospice Agency (HA) staff failed to provide care and services by not conducting weekly home visits by the licensed nurses as indicated in the patient's Plan of Care (POC - an individualized guide for the needs and services supplied to patient and their care givers/family facing a terminal illness) for five of seven sampled patients (Patient 17, Patient 18, Patient 19, Patient 21, and Patient 22). This deficient practice had the potential for not meeting the patient needs that were identified in the POC that could impact the patients health status and well-being. --- Findings: a. A review of Patient 17s clinical record indicated, the patient was admitted on 10/11/22, with diagnoses of acute ischemic heart disease (heart weakening caused by reduced blood flow to the heart). During an interview on 3/6/23, at 1:20 p.m., the Administrator (ADM) stated according to the electronic medical record, the home visits from the skilled nurse (SN) were occurring every two weeks. The ADM stated the visit frequency was not matching with the orders. During an interview on 3/7/23, at 10:52 a.m., Patient 17 stated the nurse from the HA visited her every two weeks. A review of Patient 17s clinical record titled, ";POC Summary", printed on 3/6/23, indicated, ";14. Frequency of visit...SN (skill Nurse):1 per week (1 time a week)." Further review of the electronic medical record did not indicate a nurse visit was conducted on the week of 1/15/23, 1/29/23, 2/12/23, and 2/26/23. b. A review of Patient 18s clinical record indicated, the patient was admitted on 11/17/22, with diagnoses including chronic obstructive pulmonary disease (COPD) ( group of lung diseases that block air flow and make it difficult to breath). During an interview on 3/6/23, at 1:13 p.m., the ADM stated according to the electronic medical record, the home visits from the SN were occurring every other week instead of once a week. During an interview on 3/7/23, at 11:10 a.m., Patient 18 stated the nurse from the HA visited her every week or every two weeks. The ADM stated the ordered frequency was not matching the actual nursing visit frequency. c. A review of Patient 19s ";Personal Information" indicated Patient 19 was admitted on 9/27/2022 with a terminal diagnosis of supraventricular tachycardia (rapid heart rate) and secondary diagnosis of end stage renal disease (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of Patient 19s ";POC (Plan of Care) Summary" indicated for a license vocational nurse (LVN) visit once a week plus one when needed; Registered Nurse (RN) once per two weeks plus one when needed; Spiritual counselor (SC) once per month plus one as needed; Voluntary (VOL), medical social worker (MSW), and home aide (HA) were declined. A record review of Patient 19s electronic medical record (EMR) indicated there were no LVN visit notes. A record review of Patient 19s ";Visit Note RN 1 (Registered Nurse)" dated 2/26/2023, 2/13/2023, 1/30/2023, and 1/16/2023, indicated these were the dates RN1 visited Patient 19. There was no documentation of any discussion in the interdisciplinary group meeting regarding the LVN visits were not being followed as ordered, once a week. A telephone interview on 3/7/2023 at 1:05 p.m. with Patient 19s Care Giver (CG4) with the assistance of Translation Services, operator 17762 (TS-17762), CG4 stated that the hospice nurse comes every other week. d. A review of Patient 21s ";Personal Information" indicated Patient 21 was admitted on 11/17/2022 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD- ). (group of lung diseases that block air flow and make it difficult to breath). A review of Patient 21s ";POC (Plan of Care) Summary" indicated for a skilled nurse (SN) visit once a week plus one when needed; Spiritual counselor (SC) once per month plus one as needed; Voluntary (VOL), medical social worker (MSW), and home aide (HA) were declined. A record review of Patient 21s ";Visit Note RN 1 (Registered Nurse)" dated 1/9/2023, 1/23/2023, 2/6/2023, and 2/20/2023 indicated these were the dates Patient 21 had home visits by the RN1. A record review of Patient 21s EMR indicated Patient 21 had missing SN visit for the weeks of 2/12/2023 and 2/26/2023. There was no documentation as to why these visits were missed. A telephone interview on 3/8/2023 at 2:50 p.m. with RN1, RN1 stated that she admitted Patient 21. LVN1 stated, ";I visit every two weeks." e. A review of Patient 22s ";Personal Information" indicated Patient 22 was admitted on 10/11/2022 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD)-(group of lung diseases that block air flow and make it difficult to breath). ). A review of Patient 22s ";POC (Plan of Care) Summary" indicated for a license vocational nurse (LVN) visit once a week plus one when needed; Medical social worker (MSW) one time then as needed; Spiritual counselor (SC) once per month plus one as needed; Voluntary (VOL), and home aide (HA) were declined. A record review of Patient 22s ";Visit Note RN 1 (Registered Nurse)" dated 2/21/2023, 2/7/2023, and 1/24/2023, indicated these were the dates the RN1 visited Patient 22. There was no documentation of any discussion in the interdisciplinary group meeting regarding the SN visits were being followed as ordered, once a week. A record review of Patient 22s EMR indicated missing LVN visit for the weeks of 1/29/2023 and 2/12/2023. There was no documentation why these visits were missed. A concurrent interview and record review on 3/6/2023 at 2 p.m. with the Administrator (ADM) of Patient 22s EMR, the ADM stated, ";nursing visits are not matching the frequency." A telephone interview on 3/8/2023, at 2:50 p.m., with RN1, RN1 stated that she admitted Patient 22. RN1 stated, ";I only saw her one time, on admission. I did not continue with her because I have medical issues that would have been a problem because of her TB." A telephone interview on 3/8/2023, at 11:56 a.m., with License vocational nurse 2 (LVN2) LVN2 stated, ";I was assigned for the Chinese patients, but they refused because there is a language barrier. They refused; I havent been seeing them. I notified the office about me not seeing them." A telephone interview on 3/8/2023, at 12:03 p.m., with License vocational nurse 3 (LVN3) LVN3 stated, ";I dont see any more patients since last year. Its a different language, that is why I am not seeing any more. I used a google translator". A review of the Hospice Agency (HA) Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 3/2/23, indicated, ";L0543 ... A review and audit of patient files was made for corrections and updated to ensure all care and services follow the individualized plan of care regarding frequency of licensed nurse home visits to ensure compliance."

Based on observation, interview and record review the Hospice Agency (HA) failed to educate one of seven sampled patients (Patient 18) regarding the comfort kit (small supply of medications kept at home available to rapidly treat symptoms that occur with terminal illness). This deficient practice resulted in the patient using medication incorrectly, placing the patient at risk of long-term complications. --- Findings: a. A review of Patient 18s clinical record indicated, the patient was admitted on 11/17/22, with diagnoses including chronic obstructive pulmonary disease (COPD – a group of disease that cause difficulty breathing). During an observation of the home visit, on 3/7/23, at 9:40 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed providing care to Patient 18. LVN 1 was observed reviewing the medication bottles presented to the nurse by Patient 18. During a concurrent interview and record review on 3/7/23, at 10:07 a.m., Patient 18s record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 while reviewing medications Patient 18 was taking at home. LVN 1 stated Patient 18 had duplicate comfort kit medications at home of the following: Acetaminophen (fever reducer/treat mild pain) 650 mg rectal suppository. Prochlorperazine (for nausea/vomiting) 25 mg rectal suppository, Lorazepam (for agitation/anxiety) 2mg/ml concentrated solution. During a concurrent interview and record review on 3/7/23, at 10:09 a.m., Patient 18s record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 while reviewing medications Patient 18 was taking at home. LVN 1 stated medication Morphine Sulfate (to treat strong pain, a comfort kit medication), as listed in the record, was not in the patients home. Patient 18 stated she did not have Morphine Sulfate because she took it and ran out. Patient 18 stated the last time she took Morphine Sulfate was 2 weeks ago. During a concurrent interview and record review on 3/7/23, at 10:15 a.m., Patient 18s record titled, ";Current Treatment/Medication/DME List", printed on 3/6/23, was reviewed by LVN 1 while reviewing medications Patient 18 was taking at home. LVN 1 stated Atropine (to treat excessive secretions) 1% was not listed in the record. LVN 1 stated the packaging indicated eye drops, but the label indicated to take 2 drops under the tongue every 4 hours as needed for excessive secretions. Patient 18 stated she last used Atropine a week ago to treat dry and pain in the eyes. During an interview on 3/7/23, at 11:20 a.m., LVN 1 stated Patient 18s medications were all over the place and there were a lot of discrepancies. During an interview on 3/8/23, at 12:07 p.m., the administrator (ADM) stated it was important to educate the patient regarding medications because they need to know how to take the medications, side effects, duration, how often they should take it. The ADM stated Atropine is a medication that should be used at the end of life to decrease secretions because patients who are dying produce a lot of saliva and have a difficult time swallowing. When the ADM was informed Patient 18 was taking Atropine in her eyes, the ADM stated the nurses were not providing education and should be reviewing the medications the patients are taking every visit. The ADM stated if Patient 18 continues to take Atropine for her eyes, for long term, she will have dry eyes, and this will cause eye irritation. An interview on 3/8/2023, at 12:06 p.m., with the Administrator (ADM), the ADM stated, ";Every patient should be educated on the comfort kit. The nurse needs to explain when and why the comfort kit should be used. They need to know side effects, and the reason for the need of the medication. Dont open the medication until speaking with a nurse. If the patient is stable enough and the patient does not need the comfort kit, then we dont send it. If patient is imminent then we send it right away, within 2 hours. End of life patients are unable to swallow their own saliva, we give them atropine sublingual to dry up the secretions." A review of the Hospice Agency (HA) Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 3/2/23, indicated, ";L0544 ... A review and audit of patient files was made for corrections and updated to ensure that each patient and the primary care giver(s) receive education and training to ensure compliance."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure one of seven sampled patients (Patient 17) had the medical equipment necessary to manage a patient's symptoms at home as indicated in the patient's Plan of Care (POC - an individualized guide for the needs and services supplied to patient and their care givers/family facing a terminal illness). Patient 17 was not provided at home an oxygen concentrator (medical device that gives extra oxygen) as ordered by the physician. This deficient practice had the potential for the patient not receiving oxygen as needed for respiratory difficulty that could lead to respiratory distress. --- Findings: A review of Patient 17s clinical record indicated, the patient was admitted on 10/11/22, with diagnoses of acute ischemic heart disease (heart weakening caused by reduced blood flow to the heart). During an observation of the home visit, on 3/7/23, at 10:25 a.m., Licensed Vocational Nurse 1 (LVN1) was observed providing care to Patient 17. During an interview on 3/7/23, at 10:37 a.m., Patient 17 stated she did not have an oxygen concentrator at home. The oxygen concentrator was not observed at Patient 17s home during the visit. A review of Patient 17s clinical record titled, ";POC Summary", printed on 3/6/23, indicated, ";11. DME (durable medical equipment) order date 10/31/22...DME Oxygen Concentrator 5L (liters) (stationary)..." A review of Patient 17s clinical record titled, ";POC/IDG Review", dated 3/1/23, indicated, IDG Discussion/Updated Comprehensive Assessment Review, Nursing: The patient spends the majority of the day sitting or lying down due to fatigue from advanced disease and requires considerable assistance to walk even for short distances; Patient unable to carry on normal activity or do active work and requires occasional assistance but death not imminent." A review of the Hospice Agency (HA) Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 3/2/23, indicated, ";L0550 ... A review and audit of patient files was made for corrections and updated to ensure compliance."

Based on interview and record review the Hospice Agency (HA) failed to conduct an accurate assessment that reflect the patient's current health condition, to identify the patient's eligibility for hospice services related to palliation and management of the terminal illness (an illness or condition which cannot be cured and likely to lead to someone's death) and related conditions, and the medical director did not review, document, and sign the patient's certification of terminal illness (CTI - written document by medical doctor to certify an individual's terminal diagnosis and life expectancy of six months or less if the terminal illness runs its normal course, and to establish enrollment for the Medicaid hospice program) for six of seven sampled patients, (Patient 4, Patient 17, Patient 18, Patient 19, Patient 21, and Patient 22). This deficient practice had a potential to result in the misuse of provision of the hospice services benefits that could affect the patients highest practicable mental, physical, and psychosocial well-being and its quality of life. --- a. A review of Patient 4s clinical record indicated, the patient was admitted on 6/1/22, with diagnosis of heart failure (a chronic condition in which the heart doesnt pump blood as well as it should). The record further indicated, ";referring/attending/patient choice" the Referring Doctor (RD). A review of Patient 4s ";Physicians Certification for Hospice Benefit", effective date of certification 1/27/2023 to 3/27/2023, indicated, ";Registered Nurse (RN) Prognosis summary...patient re-certified for the 4th Hospice Benefit Period with a terminal diagnosis of Heart Failure, unspecified. This patient continues to meet the Hospice Eligibility Guidelines...Per MD (Medical Director), Patient continues to meet the Hospice Criteria per Hospice Guidelines and that her terminal illness remains to be a significant contributor to poor prognosis." Patient 4's ";Physician Narrative Face to Face Summary" has no written documentation. The record further indicated, ";Medical Director Attestation/Certification I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient", the signature and date section was left blank and has no documentation. b. A review of Patient 17s clinical record indicated, the patient was admitted on 10/11/22, with diagnoses of acute ischemic heart disease (heart weakening caused by reduced blood flow to the heart). The record further indicated, ";referring/attending/patient choice" the Referring Doctor (RD). During an observation of the home visit on 3/7/23, at 10:25 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed providing care to Patient 17. Patient 17 was observed walking from the bed to the chair without use of assistive devices. During an observation, Patient 17 walked without difficulty. LVN 1 was observed asking Patient 17 about her appetite, through a language interpreter via cell phone, Patient 17 stated to LVN 1 eating was good and there were no problems with appetite. During an observation of the home visit on 3/7/23, at 10:37 a.m., LVN 1 was observed asking Patient 17 about use of the oxygen concentrator (take in air from the room and filter out nitrogen, providing higher levels of oxygen). Patient 17 told LVN 1 she did not have an oxygen concentrator. During an interview, using a language interpreter service, on 3/7/23, at 10:52 a.m., Patient 17 stated, was not informed that she has illness that could result in 6 months or less to live and was dying. Patient 17 stated, the last visit to the Primary Care Physician (PCP1) was a month ago, and thought she was stable, not getting better or worse. Patient 17 stated, she could perform and activities and leaves the house, to visit her sister and uses the walker to get in and out of the car. During an interview on 3/7/23, at 12:33 p.m., Patient 17's PCP1 stated, Patient 17 was last seen in the medical office on 2/28/23. PCP1 stated, Patient 17 did not have a terminal diagnosis resulting in 6 months or less to live. PCP1 stated she did not refer Patient 17 to hospice care and was not aware P17 was in hospice. PCP1 stated P17s prognosis was fair to good. During an interview on 3/8/23, at 1:59 p.m., the ADM stated NYHA (New York Heart Association) was a tool used to assess patients with COPD and congestive heart failure functional classification. The ADM stated, based on Patient 17 s medical record, she was classified as NYHA 4 because Patient 17 was confined to bed, dependent on walker, mainly sits, and unable to do any activities. However, during an observation and an interview with Patient 17, on 3/7/23 on the home visit, Patient 17 had no difficulty walking, and was able to visit family member. During a concurrent interview and record review of Patient 17 s clinical record titled, ";Consultation: Neurology", dated 9/19/21 was reviewed with the ADM. The ADM stated, the record was a history and physical (H&P, a document describing medical illness, treatment, and plan) from the General Acute Care Hospital (GACH), used to determine hospice eligibility. The ADM stated there was no indication in the record the patient had 6 months or less to live. The ADM stated, based on the Patient 17's History and Physical (H&P) examination, P17 did not meet the criteria for hospice care. Further review of the record did not indicate Patient 17 had a diagnosis of Acute ischemic heart disease. A review of Patient 17 s ";Physicians Certification for Hospice Benefit", effective date of certification 1/9/23 to 4/8/23, indicated, ";Certifying Physician Summary...she is awake, alert, and oriented to person, place, and time. She is ambulatory with assistance...NYHA IV. Patient requires hospice services for disease, medication, pain, and safety management due to declining condition. I certify that...has a life expectancy of six months or less if the terminal illness runs its normal course." There was no documentation of the assessment of the patient's current condition that the patient was eligible for hospice care benefits. c. A review of Patient 18s clinical record indicated, the patient was admitted on 11/17/22, with diagnoses including chronic obstructive pulmonary disease (COPD). The record further indicated, ";referring/attending/patient choice" the Referring Doctor (RD) During an observation of the home visit on 3/7/23, at 9:30 a.m., Licensed Vocational Nurse 1 (LVN 1) was observed providing care to Patient 18. Patient 18 was observed greeting the nurse and surveyor at the door and walking back to the room without the use of an assistive device. Patient 18s breathing pattern was normal with no distress observed while walking. During a concurrent observation and interview of the home visit on 3/7/23, at 9:36 a.m., LVN 1 was observed listening to Patient 18s heart and lungs. LVN 1 stated ";heart and lungs sound good". LVN 1 was observed asking questions to Patient 18 using a language interpreter via phone, the SC Patient 18 stated the oxygen concentrator was in the closet. During a concurrent observation and interview of the home visit on 3/7/23, at 9:51 a.m., a dark pasty material was noted on patients Patient 18s head. Patient 18 stated it was dye for her hair and she dyes her own hair. Patient 18 was observed interacting with LVN 1 through-out the visit, answering and asking questions with the use of the SC translating. No respiratory distress observed while patient was speaking. Patient 18 was observed walking around the room, bending over to get water bottle from the floor. Through-out the visit, Patient 18 was observed having a normal breathing pattern with no distress observed while walking. During a concurrent observation and interview of the home visit on 3/7/23, at 10:20 a.m., LVN 1 was observed looking at the durable medical equipment at home. The nebulizer (a small machine that turns liquid medicine into a mist that can be easily inhaled) was observed to be stored inside a bag in the closet. LVN 1 stated, ";I dont see any medications here for it". LVN 1 was observed inquiring about the medication for the nebulizer. Patient 18 stated she did not have the medication for the nebulizer and had not been using the nebulizer. During an interview, using a language interpreter service, on 3/7/23, at 11:10 a.m., Patient 18 stated she had a PCP. P18 stated the last time she used oxygen was 2 to 3 weeks ago when she felt uncomfortable. Patient 18 stated she did not use oxygen while sleeping. During an observation of the home visit on 3/7/23, at 11:20 a.m., Patient 18 was observed escorting nurse and surveyor outside the home. Patient 18 was observed carrying a trash bag outside the home to the driveway, to throw the trash away. Patient 18 was observed waving to the surveyors, smiling, no respiratory distress was observed. During an interview on 3/7/23, at 11:20 a.m., LVN 1 stated Patient 18 should not be hospice patients. LVN 1 stated ";you noticed she was talking a lot, but didnt have shortness of breath? Someone with COPD at advanced stage needs breaks, even with talking." During an interview on 3/7/23, at 12:33 p.m., PCP1 stated Patient 18 was a patient of the medical office for several years. PCP1 stated, ";I dont see anything considered to be terminal" for Patient 18. PCP1 stated she did not refer P18 to hospice care and was not aware Patient 18 was in hospice. PCP1 stated the last time Patient 18 was seen in the medical office was on 2/20/23. A review of Patient 18s clinical record titled, ";Physicians Certification for Hospice Benefit", effective date of certification 2/15/23 to 5/15/23, indicated, ";Physician Narrative:", did not have any notes written. The record further indicated, ";Medical Director Attestation/Certification I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient", the signature and date section did not have any documentation. d. A review of Patient 19s ";Personal Information" indicated Patient 19was admitted on 9/27/2022 with a terminal diagnosis of supraventricular tachycardia (rapid heart rate) and secondary diagnosis of end stage renal disease (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). The record further indicated, ";referring/attending/patient choice" the Referring Doctor (RD). During a telephone interview on 3/8/2023 at 9:08 a.m. with Patient 19s Primary Care Physician 2 (PCP2), PCP2 stated that his office was closed and will call tomorrow but does not recall referring P19 to hospice care. During a telephone interview on 3/9/2023 at 10:20 a.m. with P19s PCP2, PCP2 stated that he has been Patient 19 PCP for the past 2-3 years, last seeing Patient 19 last month in February. PCP2 also stated, ";I dont know why he is going to hospice. He is relatively young, and he is doing OK with that. I dont see any other reason." e. A record review of Patient 21s ";Personal Information" indicated Patient 21 was admitted on 11/17/2022 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD- breathing / air flow problems). The record further indicated, ";referring/attending/patient choice" the Referring Doctor (RD). A record review of Patient 21s Electronic Medical Record (EMR) ";Physician Certification for Hospice Benefit – Statement for First 90-day period" dated 11/17/2022 to 2/14/2023 indicated Patient 21 was referred to hospice by the Referring Doctor (RD). It also indicated the document was not signed. A record review of Patient 21s Electronic Medical Record (EMR) ";Physician Certification for Hospice Benefit – Certification #1 Statement for First 90-day period" dated 11/17/2022 to 2/14/2023 indicated the Physician Narrative and Certifying Physician Summary were blank. It also indicated the document was not signed by the Medical Director (MD) certifying P21 had a life expectance of six months or less if the terminal illness runs its normal course. A record review of Patient 21s Electronic Medical Record (EMR) ";Physician Certification for Hospice Benefit – Certification #2 Statement for First 90-day period" dated 2/15/2023 to 5/15/2023 indicated the Physician Narrative and Certifying Physician Summary were blank. It also indicated the document was not signed by the Medical Director (MD) certifying Patient 21 had a life expectance of six months or less if the terminal illness runs its normal course. f. A review of Patient 22s (P22) ";Personal Information" indicated Patient 22 was admitted on 10/11/2022 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD- breathing / air flow problems). The record further indicated, ";referring/attending/patient choice" the Referring Doctor (RD). A record review of Patient 22s Electronic Medical Record (EMR) ";Physician Certification for Hospice Benefit – Certification #2 Statement for First 90-day period (CTI)" dated 1/9/2023 to 4/8/2023 indicated the Registered Nurse (RN) Assessment Narrative, Physician Narrative and Certifying Physician Summary were blank. It also indicated the document was not signed by the Medical Director (MD) certifying Patient 22 had a life expectance of six months or less if the terminal illness runs its normal course. During a telephone interview on 3/8/2023 at 12:49 p.m. with Referring Doctor (RD), the RD stated, ";No, Ive never referred any patients for hospice care. I work for 4-5 hospice agencies I go see them if there are issues, if they die, I go give the time of death, and I also do face to face once in a while. Ive never referred patients to hospice, who put my name down." the RD stated he did not refer Patients 4, 17, 18, 19, 21, and 22 to hospice care. The RD stated he did not know who the medical director of the HA was. During an interview on 3/8/2023 at 10:25 a.m. with the Administrator (ADM), the ADM stated, ";The hospice medical director has the responsibility to review the documents sent by the PCP (primary care physician) to ensure hospice eligibility. ADM was unable to locate Patient 19, Patient 21 and Patient 22 history and physical sent by their PCP. During an interview on 3/8/23, at 10:28 a.m., the Administrator (ADM) stated according to the HAs policy, the doctor is supposed to document his/her own notes in the patients record. During an interview on 3/8/23, at 1:33 p.m., the ADM stated, ";All this situation gives the impression of fraud. They have a big mess going on. The only thing I can do is help them with education..." During an interview on 3/6/2023 at 2 p.m. with the Administrator (ADM), the ADM stated that it is important to fill out and sign the CTI because the documents is to recertify the patient for hospice care. A review of the HAs policy and procedure titled, ";Addendum 1-007.A Face-to-face policy", dated, 11/2020, indicated, ";Policy a face-to-face encounter will be performed for patients entering the third and all subsequent benefit periods." A review of the Hospice Agency (HA) Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 3/2/23, indicated, ";L0521 ... A review and audit of patient files was made for corrections and updated to ensure compliance."

This CONDITION is NOT MET as evidenced by: Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participations for Clinical Records are met as follows: --- 1.The Hospice Agency (HA) failed to ensure the contents of the Clinical Records were protected from any modifications (making partial or minor changes) from other facility personnel who was not directly assigned to four of seven sampled patients (Patient 17, Patient 19, Patient 21, and Patient 22). This deficient practice had the potential for the clinical records to contain false and inaccurate documents which can affect the formulation of patients' Plan of Care (POC - an individualized guide for the needs and services supplied to patient and their care givers/family facing a terminal illness), interventions, and can affect the quality of care and services provided by the agency to all the patients under their care. (Refer to L679). 2.The Hospice Agency (HA) failed to ensure three of seven sampled patients (Patient 18, Patient 21, and Patient 22) Clinical records were not accessed by the staff who was not directly involved in providing patient care and services to enter or delete clinical notes. This deficient practice had the potential of entering false and incorrect information in the clinical records which can affect the care planning process, interventions formulated for the care of the affected patients, and the quality of care and services provided to the affected patients. (Refer to L680). The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure provision of quality health care in a safe environment.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the contents of the Clinical Records were protected from any modifications (making partial or minor changes) by other facility personnel who was not directly assigned to four of seven sampled patients (Patient17, Patient 19, Patient 21, and Patient 22). This deficient practice had the potential for the clinical records to contain false and inaccurate documents which can affect the formulation of patients' Plan of Care (POC - an individualized guide for the needs and services supplied to patient and their care givers/family facing a terminal illness), interventions, and quality of care and services provided all the patients receiving hospice care benefits. --- Findings: a). A review of Patient 17s clinical record indicated, the patient was admitted on 10/11/2022, with a diagnoses of acute ischemic heart disease (a condition when heart is not getting enough blood supply and oxygen). During an interview on 3/6/2023 at 11:30 a.m., the Administrator (ADM) stated members of the Interdisciplinary Group (IDG - a team who is responsible for the holistic care of the hospice beneficiary) at minimum included the doctor, medical social worker (MSW), registered nurse, and chaplain. The ADM stated the doctor, social worker, chaplain, and registered nurse needed to participate in the IDG group meetings and validate their input by reviewing the notes entered and signing the patient record to validate their attendance and their input . During an interview on 3/8/2023, at 1:06 p.m., the Administrator Designee (AD) stated after the last visit from California Department of Public Health (CDPH - a state department), the IDG disciplines (Medical Director (MD), MSW, Nursing, and Chaplain) were directed to document their summaries and sign it, in the electronic medical record. A review of Patient 17s record titled, ";Audit Log", dated from 2/27/2023 to 3/8/2023, indicated the AD modified ";module IDG" dated ";2/1/2023 Spiritual-Discussion" on ";3/2/2023 at 7:30 p.m.". The record indicated the previous value was blank and the current value indicated, ";When the Chaplain arrived for spiritual and emotional care...This is a Chinese speaking family. The Chaplain was able to provide Chinese language support and emotional care to the patients family..." A review of Patient 17s record titled, ";Audit Log", dated from 2/27/2023 to 3/8/2023, indicated the AD modified ";module IDG" for the following dates: ";1/18/2023 Summary Discussion, previous value Skilled Nurse (SN) to continue home visit per frequency as ordered. Continue with plan of care, current value, ...Prior to provision of care, hospice discussed service, benefits and philosophy in detail, patient...is aware if she chooses not to continue hospice call anytime, or choose to revoke hospice, understanding observed..." ";2/1/2023 Psychosocial-discussion, previous value", was blank, ";Current value MSW: Declined..." ";2/1/2023 Summary discussion, previous value, continue with plan of care, current value, Patient is awake and verbally responsive...SN administered PO medication to relieve pain...Pt verbalized understanding of above education...SN will continue to follow up..." ";2/15/2023 Psychosocial-Discussion, previous value" blank, ";current value MSW: Declined..." ";2/15/2023 Spiritual-Discussion, previous value, The chaplain will continue to provide spiritual and emotional support..., current value, When the Chaplain arrived for spiritual and emotional care...The chaplain was able to provide Chinese language support and emotional care to the patient..." ";2/15/2023 Summary Discussion previous value, continue with plan of care, current value, Patient was awake, alert and oriented x 3 throughout the assessment..." ";3/1/2023 Psychosocial-Discussion, previous value" blank, ";current value, MSW Declined..." ";3/1/2023 Spiritual-Discussion, previous value", blank, ";current value, when the Chaplain arrived for spiritual and emotional care..." ";3/1/2023 Summary Discussion, previous value", blank, ";current value, The patient spends the majority of the day sitting or lying down..." b. A review of Patient 19s ";Personal Information" indicated Patient 19 was admitted on 9/27/2022 with a terminal diagnosis of supraventricular tachycardia (rapid heart rate) and secondary diagnosis of end stage renal disease (kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of Patient 19s record titled, ";Audit log", dated from 2/27/2023 to 3/8/2023, indicated the AD modified module ";IDG" dated: 1. ";2/15/2023 Spiritual-Discussion" on ";3/2/2023 at 6:58 p.m." and 2. ";2/1/2023 Spiritual-Discussion" on ";3/2/2023 at 6:56 p.m." and 3. ";1/18/2023 Spiritual-Discussion" on ";3/2/2023 at 6:53 p.m." All three entries indicated the previous value as ";The chaplain will continue to provide spiritual and emotional support according to the patients plan of care. The current value indicated, ";When the Chaplain arrived for spiritual and emotional care...This is a Chinese speaking family. The Chaplain was able to provide Chinese language support and emotional care to the patient..." c. A review of Patient 21s ";Personal Information" indicated Patient 21 was admitted on 11/17/2022 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD - breathing and air flow problems). A review of Patient 21s record titled, ";Audit log", dated from 2/27/2023 to 3/8/2023, indicated the AD modified modules: A. ";IDG" dated: 1. ";3/1/2023 Spiritual-Discussion" on ";3/2/2023 at 10 p.m." and 2. ";2/15/2023 Spiritual-Discussion" on ";3/2/2023 at 9:51 p.m." and 3. ";2/10/2023 Spiritual-Discussion" on ";3/2/2023 at 9:50 p.m." and 4. ";2/1/2023 Spiritual-Discussion" on ";3/2/2023 at 9:47 p.m." and 5. ";1/18/2023 Spiritual-Discussion" on ";3/2/2023 at 9:45 p.m." Entry number one indicated the ";previous value" was blank. Entry number two to five indicated the previous value was documented as ";The chaplain will continue to provide spiritual and emotional support according to the patients plan of care. All five entries indicated the current value to be, ";The Chaplain was able to contact the patient and the patients care giver to give spiritual and emotional care..." B. ";Certification MD" dated: 1. ";2/15/2023 Physician Narrative: Face to Face Summary (if applicable)" on ";3/8/2023 at 9:51 a.m." and 2. ";2/15/2023 Physician Narrative: Certifying Physician Summary" on ";3/8/2023 at 9:51 a.m." and 3. ";11/17/2022 Physician Narrative: Face to Face Summary (if applicable)" on ";3/8/2023 at 9:50 a.m." and 4. ";11/17/2022 Physician Narrative: Certifying Physician Summary" on ";3/8/2023 at 9:50 a.m." All entries indicated the ";previous values" were blank. Entries into the ";current value" for ";Physician Narrative: Face to Face Summary (if applicable)" to be ";The patient is a... 5. Code undecided-will continue to discuss". Entries into the ";current value" for ";Physician Narrative: Certifying Physician Summary" to be ";This is a... has a life expectancy of six months or less if the terminal illness runs its normal course." d. A review of Patient 22s ";Personal Information" indicated Patient 22 was admitted on 10/11/2022 with a primary diagnosis of COPD. A review of Patient 22s record titled, ";Audit log", dated from 2/27/2023 to 3/8/2023, indicated the AD modified modules: A. ";IDG" dated: 1. ";3/1/2023 Spiritual-Discussion" on ";3/2/2023 at 7:20 p.m." and 2. ";2/15/2023 Spiritual-Discussion" on ";3/2/2023 at 7:17 p.m." and 3. ";2/1/2023 Spiritual-Discussion" on ";3/2/2023 at 7:14 p.m." and 4. ";1/18/2023 Spiritual-Discussion" on ";3/2/2023 at 7:11 p.m." Entry number one indicated the ";previous value" was blank. Entry numbers two to three indicated the previous value was documented as ";The chaplain will continue to provide spiritual and emotional support according to the patients plan of care. Entry number 4 indicated the previous value was documented as ";IHSS assistance " (In Home Supportive Services (IHSS) - a program provides in-home assistance to eligible individuals). All four entries indicated the current value to be, ";The Chaplain was able to contact the patient and the patients..." B. ";Certification MD" dated: 1. ";1/9/2023 Physician Narrative: Face to Face Summary (if applicable)" on ";3/8/2023 at 9:56 a.m." and 2. ";1/9/2023 Physician Narrative: Certifying Physician Summary" on ";3/8/2023 at 9:58 a.m." Both entries indicated the ";previous value" were blank. Entries into the ";current value" for ";Physician Narrative: Face to Face Summary (if applicable)" to be ";The patient is a... 4. Code undecided-DNR". Entries into the ";current value" for ";Physician Narrative: Certifying Physician Summary" to be ";This is a... has a life expectancy of six months or less if the terminal illness runs its normal course." A review of Patient 22s record titled, ";Audit log", dated from 2/27/2023 to 3/8/2023, indicated the Registered Nurse 1 (RN1) modified modules ";Visit note" dated: 1. ";2/21/2023 Deleted" on ";3/7/2023 11:33:56 a.m." and 2. ";2/7/2023 Deleted" on ";3/7/2023 11:33:41 a.m." and 3. ";1/24/2023 Deleted" on ";3/7/2023 11:33:20 a.m." The record indicated the ";previous values" and ";current values" were blank. A record review of Patient 22s ";Visit Note RN" dated 2/21/2023, 2/7/2023, and 1/24/2023, were provided by Office Staff (OS) on 3/6/2023, indicated RN1 visited and documented the visit for Patient 22. A telephone interview on 3/8/2023 at 1:06 p.m. with AD, AD stated the MD had been documenting his own notes in the electronic medical record, since the last time CDPH had surveyed the agency. The AD stated the MD had learned how to log in to the electronic record to document and sign notes. AD also stated, ";We were getting information based on the nurses assessment. Now he is the one that is doing his Certificate of Terminal Illness (CTI), he documents on the CTI." A telephone interview on 3/8/2023 at 2:50 p.m. with RN1, RN1 stated that she admitted Patient 22, but that she only saw her one time. RN1 stated, ";I only saw her one time, on admission. I did not continue with her because I have medical issues that would have been a problem because of her TB." RN1 stated she did not recall if she deleted nursing notes on 3/7/2023. RN1 also stated that no one else has her log in information. A review of the Hospice Agency (HA) Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 3/2/2023, indicated, ";L0679 ... A review and audit of patient files was made for corrections and updated to ensure compliance."

Based on interview and record review, the Hospice Agency (HA) failed to ensure three of seven sampled patients (Patient 18, Patient 21, and Patient 22) Clinical records were not accessed by the staff who was not directly involved in providing patient care and services to enter or delete clinical notes. This deficient practice had the potential of entering false and incorrect information in the clinical records which can affect the care planning process, interventions formulated for the care of the affected patients, and the quality of care and services provided to the affected patients. --- Findings: a. A review of Patient 18s clinical record indicated Patient 18 was admitted on 11/17/2022, with diagnoses including chronic obstructive pulmonary disease (COPD - breathing and air flow problems). During an interview on 3/8/2023, at 10:25 a.m., the Administrator (ADM) stated a transcriber (someone who makes a handwritten or hand typed copy of either live or recorded spoken content) can document on behalf of the doctor. The ADM stated transcribing was legal and the doctor had the responsibility to review the documentation for accuracy and sign the document. During an interview on 3/8/2023, at 10:28 a.m., the ADM stated she reviewed the policy titled ";Medical Director Role" and dated 11/2020. The ADM stated the policy says the doctor is supposed to document his own notes. The ADM stated nothing in the policy stated the agency can use a transcriber to enter notes in the CTI (Certificate of Terminal Illness). During an interview on 3/8/2023, at 1:06 p.m., the Administrator Designee (AD) stated the Medical Director (MD) had been documenting his own notes in the electronic medical record, since the last time the California Department of Public Health (CDPH) had surveyed the agency. The AD stated the MD had learned how to log in to the electronic record to document and sign notes. During a concurrent interview and record review on 3/8/2023, at 1:10 p.m., Patient 18s record titled, ";Audit log", dated from 2/27/2023 to 3/8/2023, was reviewed with the AD. The record indicated the AD, modified module ";certification MD" for date ";2/15/2023" on ";3/8/2023 9:43 a.m.". The record indicated the previous value was blank and the current value indicated, ";This is a ...with primary diagnosis of Chronic obstructive pulmonary disease...I certify that (another patients name, not Patient 18) has a life expectancy of six months or less if the terminal illness runs its normal course". The AD stated the MD asked him to assist in inputting the information. The AD stated he documented the notes based on the nursing documentation. The AD stated the MD was responsible in reviewing, completing, and signing the note. The AD stated it was not okay to document, but the MD had asked him to help put in the nurses assessment. The AD stated he did not know if it was the right thing to do because the MD still has to review it and sign it. b. A review of Patient 21s ";Personal Information" indicated Patient 21 was admitted on 11/17/2022 with a terminal diagnosis of COPD. A review of Patient 21s record titled, ";Audit log", dated from 2/27/2023 to 3/8/2023, indicated the Administrator Designee (AD) modified module ";Certification MD" dated: 1. ";2/15/2023 Physician Narrative: Face to Face Summary (if applicable)" on ";3/8/23 at 9:51 a.m." and 2. ";2/15/2023 Physician Narrative: Certifying Physician Summary" on ";3/8/23 at 9:51 a.m." and 3. ";11/17/2022 Physician Narrative: Face to Face Summary (if applicable)" on ";3/8/23 at 9:50 a.m." and 4. ";11/17/2022 Physician Narrative: Certifying Physician Summary" on ";3/8/23 at 9:50 a.m." All entries indicated the ";previous value" were blank. Entries into the ";current value" for ";Physician Narrative: Face to Face Summary (if applicable)" to be ";The patient is a... 5. Code undecided-will continue to discuss". Entries into the ";current value" for ";Physician Narrative: Certifying Physician Summary" to be ";This is a... has a life expectancy of six months or less if the terminal illness runs its normal course." c. A review of Patient 22s ";Personal Information" indicated P22 was admitted on 10/11/2022 with a primary diagnosis of Chronic obstructive pulmonary disorder (COPD- breathing / air flow problems). A review of Patient 22s record titled, ";Audit log", dated from 2/27/23 to 3/8/23, indicated the AD modified module ";Certification MD" dated: 1. ";1/9/2023 Physician Narrative: Face to Face Summary (if applicable)" on ";3/8/2023 at 9:56 a.m." and 2. ";1/9/2023 Physician Narrative: Certifying Physician Summary" on ";3/8/2023 at 9:58 a.m." Both entries indicated the ";previous value" were blank. Entries into the ";current value" for ";Physician Narrative: Face to Face Summary (if applicable)" to be ";The patient is a... 4. Code undecided-DNR". Entries into the ";current value" for ";Physician Narrative: Certifying Physician Summary" to be ";This is a... has a life expectancy of six months or less if the terminal illness runs its normal course." A review of Patient 22s record titled, ";Audit log", dated from 2/27/2023 to 3/8/2023, indicated the Registered Nurse 1 (RN1) modified modules ";Visit note" dated: 1. ";2/21/2023 Deleted" on ";3/7/2023 11:33:56 a.m." and 2. ";2/7/2023 Deleted" on ";3/7/2023 11:33:41 a.m." and 3. ";1/24/2023 Deleted" on ";3/7/2023 11:33:20 a.m." The record indicated the ";previous values" and ";current values" were blank. A record review of Patient 22s ";Visit Note RN (Registered Nurse)" dated 2/21/2023, 2/7/2023, and 1/24/2023, were provided by Office Staff (OS) on 3/6/2023 and indicated RN1 visited and documented the visit for Patient 22. A telephone interview on 3/8/2023 at 1:06 p.m. with AD, AD stated the Medical Director (MD) had been documenting his own notes in the electronic medical record, since the last time the CDPH had surveyed the agency. The AD stated the MD had learned how to log in to the electronic record to document and sign notes. AD also stated, ";We were getting information based on the nurses assessment. Now he is the one that is doing his CTI, he documents on the CTI." A telephone interview on 3/8/2023 at 2:50 p.m. with RN1, RN1 stated that she admitted Patient 22, but that she only saw her one time. RN1 stated, ";I only saw her one time, on admission. I did not continue with her because I have medical issues that would have been a problem because of her TB." RN1 stated she did not recall if she deleted nursing notes on 3/7/2023. RN1 also stated that no one else has her log in information. A review of the Hospice Agency (HA) Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 3/2/2023, indicated, ";L0680 ... A review and audit of patient files was made for corrections and updated to ensure compliance."

Based on observation, interview, and record review, the hospice agency failed to ensure the Condition of Participation for Initial and Comprehensive Assessment of Patients was met as follows: --- 1.The Hospice Agency failed to accurately assess the patient's eligibility for hospice services related to palliation and management of the terminal illness (an illness or condition which cannot be cured and likely to lead to someone's death) and related conditions, and the medical director did not review, document and sign the patient's certification of terminal illness (CTI, written document by medical doctor to certify an individual's terminal diagnosis and life expectancy of six months or less if the terminal illness runs its normal course, and to establish enrollment for the Medicaid hospice program) for five of 6 sampled patients, (Patient 4, 13, 17, 18 and 19). This deficient practice had a potential to result in the misuse of provision of the hospice services benefits that could affect the patients highest practicable mental, physical and psychosocial well-being and its quality of life. (Refer to L521). 2. The Hospice Agency (HA) failed to conduct an assessment of the peritoneal dialysis (a treatment for kidney failure that uses lining of the abdomen or belly to filter blood, remove toxins and excess fluid in the body) access (a flexible, hollow plastic tube that's surgically placed in lower abdomen) for one of 6 sampled patients, (Patient 19). This deficient practice resulted in the hospice agency's inability to ensure the provision of quality health and had a potential for mismanagement of the patient's peritoneal dialysis(Refer to L522). 3. The Hospice Agency failed to ensure the Interdisciplinary Group (IDG, a group of individual who works together to meet hospice patient care needs) maintain an updated comprehensive assessment for one of 6 sampled patients, Patient 19. The HA did not identify and conduct an assessment for Patient 19's peritoneal dialysis (a treatment for kidney failure that uses lining of the abdomen or belly to filter blood, remove toxins and excess fluid in the body) access (a flexible, hollow plastic tube that's surgically placed in lower abdomen).This deficient practice resulted in the HA not identifying the patient's care need and has a potential for the patient's peritoneal dialysis (PD) access not being managed that could lead to complication from PD and infection. (Refer to L524). 4. The Hospice Agency failed to ensure the medications listed in the patient's medication profile were available, for three of 6 sampled patients (Patient 17, 18 and 19).This deficient practice had the potential for adverse effect on the patient health condition when the medication are not administered timely which can affect the health and safety of the patients. (Refer to L530). 5. The Hospice Agency failed to conduct an initial bereavement (a period of time characterized by grief or mourning after the loss of loved one) assessment for 3 of six sampled patients (Patients 17, 18 and 19).This deficient practice had the potential to impact a family members' abilities to cope with the patients' death. (Refer to L531). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated federal compliance to ensure safety and the highest quality care and services were provided to the patients under their care.

Based on interview and record review, the hospice agency failed to accurately assess the patient's eligibility for hospice services related to palliation and management of the terminal illness (an illness or condition which cannot be cured and likely to lead to someone's death) and related conditions, and the medical director did not review, document and sign the patient's certification of terminal illness (CTI, written document by medical doctor to certify an individual's terminal diagnosis and life expectancy of six months or less if the terminal illness runs its normal course, and to establish enrollment for the Medicaid hospice program) for five of 6 sampled patients, (Patient 4, 13, 17, 18 and 19). This deficient practice had a potential to result in the misuse of provision of the hospice services benefits that could affect the patients highest practicable mental, physical and psychosocial well-being and its quality of life. --- a). A review of Patient 4s clinical record indicated Patient 4 was admitted to the Hospice Agency (HA) on 6/1/22, with a diagnosis of heart failure (a chronic condition in which the heart doesnt pump blood as well as it should). A review of Patient 4s clinical record titled, ";Physicians Certification for Hospice Benefit", for certification period 11/28/22 to 1/26/23, indicated, ";certification is based on face-to-face encounter". The record did not indicate a physician narrative or a physician signature. b. A review of Patient 13's electronic clinical record indicated a start of hospice care date of 5/18/22, with a terminal diagnosis of atherosclerosis heart disease of native coronary artery (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow), with unspecified angina pectoris (chest pain or discomfort). A review of Patient 13's "Physician's Certification for Hospice Benefit," for the third 60- day period from 11/14/2022 to 1/12/2023, Patient 13's terminal diagnosis was atherosclerosis heart disease of native coronary artery with unspecified angina pectoris. There was no documented evidence the hospice medical director signed the CTI that Patient 13 had a life expectancy of six months or less if the terminal illness runs its normal course. c) A review of Patient 17's clinical record indicated, the patient was admitted on 10/11/22, with diagnoses of acute ischemic heart disease (when the heart weakening caused by reduced blood flow to the heart). On 1/14/23, at 12:14 p.m., a telephone interview the MD stated, he did not see the patient physically the nurses just called him about the patient condition. The MD stated, he gave permission to do the electronic signature. And he does not know his user name. A review of Patient 17's patients certificate of terminal illness (CTI) for first certification 10/11/22 through 1/8/23, documented by the attending physician indicated, "; primary diagnoses of acute ischemic heart disease. Patient past history includes but not limited to right hemiplegia, pain in right and leg, and numbness on fingers on the right hand. She is awake, alert and oriented to person, place and time. She is ambulatory with assistance. Patient requires hospice services for disease, medication, pain and safety management due to declining condition. I certify that her life expectancy of six months or less if the terminal illness runs its normal course." The attending physician who is the agencys medical director attested/certified ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of patient". That he reviewed and electronically signed the document. d). A review of Patient 18's clinical record indicated, the patient was admitted on 11/17/22, with diagnoses taken as chronic obstructive pulmonary disease and heart disease unspecified (COPD). A review of Patient 18s clinical record titled, ";Physicians certification for Hospice Benefit", for certification period 11/17/22-2/14/23, indicated, ";Certification is based on medical history, record and patient status, team assessment, face to face encounter...I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." e). A review of Patient 19's electronic clinical record indicated a start of hospice care date of 9/27/22, with a terminal diagnosis of supraventricular tachycardia (is a rapid heartbeat that develops when the normal electrical impulses of the heart are disrupted) and end stage renal disease ( is a medical condition in which kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of Patient 19's "Physician's Certification for Hospice Benefit," for the second 90- day period from 12/26/2022 to 3/25/2023 with Patient 19's terminal diagnosis supraventricular tachycardia and end stage renal disease. There was no documented evidence the hospice medical director signed the CTI that Patient 19 had a life expectancy of six months or less if the terminal illness runs its normal course. On 1/14/23 at 12:09 p.m., during an interview with the Medical Director/doctor (MD), he stated that as a medical director, he only oversees and do not admit the patients, stated he did not referred to the hospice agency and did not see the patients face to face. MD stated, his impression of his role as a medical director was not to conduct a face to face and the hospice nurse would call him about these conditions, would tell the hospice nurses how to manage the care of the patients since he have not seen the patients and have not physically examined the patients. MD stated that whenever the hospice nurses bring the certification, he signs the paper, and he is not good with computers. MD stated that he has given permission to the hospice nurses to log in and sign under his name and the hospice nurses have his permission to go in and sign his name in the CTI in Hospice MD electronic medical records for patients. MD stated that the lack of signature on the CTI means that it has not come to his attention. A review of the hospice agencys policy titled, ";Certification of Terminal Illness", dated 11/2020, indicated that to ensure physician certification of terminal illness and authorization for hospice services in accordance with applicable state and federal regulations and payer requirements and at recertification, the hospice medical director must compose and sign the narrative based on a review of the patients medical record or if applicable, examination of the patient.

Based on observation, interview and record review, the hospice agency (HA) failed to conduct an assessment of the peritoneal dialysis (a treatment for kidney failure that uses lining of the abdomen or belly to filter blood, remove toxins and excess fluid in the body) access (a flexible, hollow plastic tube that's surgically placed in lower abdomen) for one of 6 sampled patients, (Patient 19). This deficient practice resulted in the hospice agency's inability to ensure the provision of quality health and had a potential for mismanagement of the patient's peritoneal dialysis access and infection of the access. --- A review of Patient 19's (P19) electronic clinical record indicated a start of hospice care date of 9/27/22, with a terminal diagnosis of supraventricular tachycardia (a rapid heartbeat that develops when the normal electrical impulses of the heart are disrupted) and end stage renal disease (a medical condition in which kidneys cease functioning on a permanent basis). On 1/13/23, at 9:30 am, a home visit was conducted with Director of Patient Care Services (DPCS) to P19s residence. P19 was resting comfortably in the room, alert and awake, and in no acute distress. DPCS performed hand hygiene and started the nurse visit. During an observation, P19 has a peritoneal dialysis access (PDA) located on his right abdominal area, covered with clean dressing with no active bleeding, stain or discharges. During an interview P19 stated, he had the peritoneal dialysis before started in hospice program, P1stated, his family member helped him to clean and replace the bandage of the PDA every day and after each dialysis. Pt 19 stated, he knew how to connect the portable PD machine to the access but with the help of his family member. P19 stated, the supplies were provided by the hospice agency, A review of P19s clinical records did not indicated, the skilled nurse (SN) conducted an assessment and documented the patient's PD. On 1/14/23, at 10:00 am, during an interview the DPCS stated, a complete assessment should have been done for patients so hospice agency can address of any issues arise. DPCS stated, the SN has to conduct an assessment for each visit to identify for any potential problems. DPCS stated, P19 has no assessment of the PD. A review of hospice agencys policy and procedure titled, ";Ongoing Comprehensive Assessment", revised November 2020, indicated that during each home visit, the case manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment, the nurse will assess each patient on each visit which include skin integrity.

Based on interview and record review, the hospice agency failed to ensure the Interdisciplinary Group (IDG, a group of individual who works together to meet hospice patient care needs) maintain an updated comprehensive assessment for one of 6 sampled patients, Patient 19. The HA did not identify and conduct an assessment for Patient 19's peritoneal dialysis (a treatment for kidney failure that uses lining of the abdomen or belly to filter blood, remove toxins and excess fluid in the body) access (a flexible, hollow plastic tube that's surgically placed in lower abdomen). This deficient practice resulted in the HA not identifying the patient's care need and has a potential for the patient's peritoneal dialysis (PD) access not being managed that could lead to complication from PD and infection. --- On 1/13/23, a review of Patient 19's electronic clinical record indicated a start of hospice care date of 9/27/22, with a terminal diagnosis of supraventricular tachycardia (a rapid heartbeat that develops when the normal electrical impulses of the heart are disrupted) and end stage renal disease (a medical condition in which kidneys cease functioning on a permanent basis). A review of the plan of care/Interdisciplinary group review (POC/IDG) dated 10/12/22, 11/9/22, 11/23/22, 12/7/22, 12/21/22 and 1/4/22 indicated the SN visit frequency for Patient 19 was once a week and one visit as needed per week for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT), and administration and education on medication. The notes did not identify and has not addressed Patient 19s peritoneal dialysis access. On 1/14/2023, at 10:30 a.m., during an interview the Director of Patient Care Services (DPCS) was not able to provide the documentation on Patient 19s peritoneal dialysis access and was not identified or discussed during IDG meetings. DPCS stated that patients with existing lines, devices attached should have been assessed and discussed in every IDG meeting. A review of the agency's policy and procedure titled, "Interdisciplinary Group Meeting", undated, indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program.

Based on observation, interview, and record review, the hospice agency failed to ensure the medications listed in the patient's medication profile were available, for three of 6 sampled patients (Patient 17, 18 and 19). This deficient practice had the potential for adverse effect on the patient health condition when the medication are not administered timely which can affect the health and safety of the patients. --- a) A review of Patient 17's clinical record indicated, the patient was admitted to hospice agency (HA) on 10/11/22, with diagnoses of acute ischemic heart disease. On 1/13/23, at 10 a.m., during the home visit, Patient 17 was not available. Patient 17's medication observed and there were only three bottles as follows: Lisinopril 20 milligrams (mg) one tablet daily (for high blood pressure), amlodipine 5 mg one tablet every evening (for high blood pressure), and docusate sodium 100 mg daily ay bedtime as needed (stool softener). A review of Patient 17's medication profile (list of medication) indicated the following medications and were not available for patient to take: Atorvastatin (medication used to lower cholesterol (a waxy substance in the blood cells) 20 mg daily comfort kit medications not available: Levsin 0.125 mg/ml drops 1 ml sublingual every four hours as needed for excessive secretions Bisacodyl 10 mg rectal suppository I suppository daily as needed for constipation Acetaminophen 650 mg / rectal I suppository per rectum every four hours as needed for mild pain/fever Lorazepam 2 mg/ml concentrate solution 0.25 mg ml sublingual every four hours as needed for anxiety/anxiety Morphine Sulfate 20 mg/ml 0.25 ml sublingual every 2 hours as needed for severe pain/shortness of breath Prochlorperazine 25 mg rectal suppository I suppository every 12 hours as needed for nausea/vomiting. On 1/14/23, RN indicated that Patient 17s comfort kit was in the refrigerator and her room mate did not show up. A review of pharmacy receipt indicated, the comfort kit was delivered on 1/12/23 6 p.m. During a concurrent interview with Registered Nurse (RN) confirmed that Patient 17s comfort kit was just delivered on 1/12/23, instead of being delivered since admission 10/11/22. b). A review of Patient 18's clinical record indicated, the patient was admitted to HA on 11/17/22, with diagnoses of chronic obstructive pulmonary disease (COPD) and heart disease unspecified. On 1/14/23, at 10 a.m., during a home visit at Patient 18s residence, was observed alert, oriented and spoke of foreign language only. Patient 18 was able to ambulate in slow steady gait and has a voice activated machine that can interpret the conversation. During an interview with the patient, asked regarding the hospice services, that her life expectancy was 6 months, she was surprised and stated that she had only heart problem and did not think she would die soon. A review of Patient 18's medication profile, the following medication were not available. a. Bactrim 400-80 mg tablet. There was no frequency and indication and was not available. b. Olmesartan Medoxomil 40 mg one tablet daily for high blood pressure was not available. c. Restasis 0.05% multidose ophthalmic emulsion one drop every 12 hours was not available c. c.) On 1/13/23, a review of Patient 19's electronic clinical record indicated a start of hospice care date of 9/27/22, with a terminal diagnosis of supraventricular tachycardia (is a rapid heartbeat that develops when the normal electrical impulses of the heart are disrupted) and end stage renal disease ( is a medical condition in which kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a home visit observation, concurrent review and interview on 1/13/23, at 9:30 a.m., the Director of Patient Care Services was observed reviewing the medications of Patient 19. During an observation of the comfort kit medications (a group of medications used at the end of life to lessen symptoms), Patient 19s family member stated that it was delivered on 1/12/23. Patient 19 stated, the comfort kit was not delivered to their residence since admission. Patient 19 and his wife stated the comfort kit was not available and had no comfort kit medications at home until 1/12/23. The DPCS stated it was important to have all the medications the patient takes as listed on the medication profile to ensure medications are taken safely. DPCS stated that he is not aware the patient did not receive his comfort kit before.

Based on interview and record review, the hospice agency failed to provide initial bereavement (a period of time characterized by grief or mourning after the loss of loved one) assessment for 3 of six sampled patients (Patients 17, 18 and 19). This deficient practice had the potential to impact a family members' abilities to cope with the patients' death. --- a). A review of Patient 17's medical records indicated, the patient was admitted on 10/11/22, with diagnoses of acute ischemic heart disease. A review of Patient 17's certification period of 10/11/22 through 1/8/23, the IDG/POC indicated, the review was conducted by Medical Director (MD), LCSW, RN and SC. However, the IDG dated 10/26/22; 11/9/22; 11/23/22; 12/7/22; 12/21/22 and 1/4/23, was done and electronically signed by an RN only. During an interview with Staff 1 on 1/12/23, at 2 p.m. stated, the HA staff had been doing a ";Zoom meeting" however, there was no documentation of the meeting. A review of Patient 17's medical record, Patient 17 has no bereavement assessment, psychosocial assessment and volunteer assessment. b). A review of Patient 18's medical records indicated, the hospice agency admitted the patient on 11/17/22, with diagnoses of chronic obstructive pulmonary disease and heart disease (COPD unspecified. A review of Patient 18's plan of care/interdisciplinary group (POC/IDG) dated 11/17/22, indicated, discussion documented that the following Spiritual – was informed of patient admission and will be calling the patient/family to schedule appointment for an initial chaplain visit. The Spiritual Care coordinator For spiritual assessment within 5 days of admission to identify spiritual needs/support for patient/family and primary caregiver. Psychosocial - MSW (Medical Social Worker) was informed of patient admission and will be calling the patient family to schedule an appointment for an initial MSW counselling and support, evaluate and assess for initial evaluation within 5 days of admission for Psychosocial Counselling and support. Other/Physician – Volunteer Services are offered but are not needed at this time. Continue to offer Services. Certified Home health aide services are offered but are not needed at this time. Continue to offer services. The comprehensive assessment indicated, for the above IDGs was being done by an RN and there were no initial assessment by the MSW, Spiritual Counselling, MD, Bereavement and Volunteer, documented and has no signature of the responsible staff. c). A review of Patient 19's electronic clinical record indicated a start of hospice care date of 9/27/22, with a terminal diagnosis of supraventricular tachycardia (a rapid heartbeat that develops when the normal electrical impulses of the heart are disrupted) and end stage renal disease (a medical condition in which kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of Patient 19's Plan of Care/Inter-Disciplinary Group review (POC/IDG) dated 2/3/22, indicated that a skilled nurse (SN) is scheduled to visit patient three times a week for a routine care and was updated to continuous level of care due to Patient 9s change in condition to include skilled nursing services continuously for assessments, clinical care, support as needed for ongoing evaluation and registered nurse (RN) to evaluate patient 9 every 24 hours. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 1/4/23, indicated skilled nurse (SN) visit once a week on current recertification period from 12/26/22 to 3/25/23. A review of Patient 19s Plan Of Care/Interdisciplinary Group Review dated 10/12/22 indicated the goal of bereavement is for patient/family will look forward to and planning for the future in the next 2 weeks and will learn to accept that dying is another phase of life in the next 2 weeks. Interventions indicated that hospice agency will encourage patient/family/caregiver expression of feelings and concerns associated with the recommended change in the level of care, to assist family with the grieving process through attentive listening and understanding their potential loss, to encourage and facilitate connections with sources of faith and hope, to convey confidence in the family/patient ability to handle a situation and to encourage conversation which assists the patient/family in sorting out psychosocial and spiritual concerns. A review of Patient 19's clinical records indicated that there was no initial bereavement risk assessment conducted. During an interview with the Director of Patient Care Services (DPCS) on 1/13/23, at 11:45 a.m., the DPCS stated that a bereavement assessment should be conducted on admission. The DPCS further stated, the HA did not conduct an initial bereavement assessment on admission for Patient 19. . During a telephone interview with the Medical Social Worker (MSW) on 1/13/23, at 11:50 a.m., the MSW stated that the patient and family refused to have a bereavement assessment, however, there was no indication of any documented evidence or communication notes were made. A review of the agency's policy and procedure titled "Bereavement Assessment", undated, indicated a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented as needed.

Based on interview and record review, the Hospice Agency failed to ensure the interdisciplinary group (IDG) identify the physical, psychosocial, emotional and spiritual needs of patients, related to terminal illness was addressed to promote the patients well-being, comfort and dignity throughout the dying process and updated at least every 15 days for six out of 12 sampled patients (Patient 4, 13, 17, 18, 19 and 20). This deficient practice had potential for psychological issues that could prevent from reaching their care goals. --- a). A review of Patient 4s medical record indicated Patient 4 was admitted to the Hospice Agency (HA) on 6/1/22, with a diagnosis of heart failure (a chronic condition in which the heart doesnt pump blood as well as it should). A review of Patient 4s clinical records titled, ";POC/IDG Review", dated 1/4/23; 12/21/22; 12/7/22; 11/23/22;11/9/22, did not indicate the doctor, registered nurse, medical social worker, and chaplain had attended the meeting. Further review of these records did not indicate notes for section titled ";IDG discussion/updated Comprehensive Assessment Review". b). A review of Patient 13's electronic medical record indicated a start of hospice care date of 5/18/22, with a terminal diagnosis of atherosclerosis heart disease of native coronary artery (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow), with unspecified angina pectoris (chest pain or discomfort). A review of Patient 13s Plan of Care/Interdisciplinary Group review dated 10/12/22, 10/26/22, 11/9/22, 11/23/22 and 12/7/22, indicated incomplete IDG signatures from IDG team attendees (Medical Director, Medical Social Worker, Registered Nurse and Chaplain) and no documented evidence of an evaluation of Patient 13s response to care, treatment, services provided and there was no progress toward desired outcome documented every 15 days. c) A review of Patient 17's medical records indicated, the patient was admitted on 10/11/22, with diagnoses of acute ischemic heart disease. A review of Patient 17's certification period of 10/11/22 through 1/8/23, the IDG/POC indicated, review was conducted by MD, LCSW, RN and SC. However, the IDG dated 10/26/22; 11/9/22; 11/23/22; 12/7/22; 12/21/22 and 1/4/23, was only done and electronically signed by an RN. During an interview with Staff 1 on 1/12/23, at 2 p.m. stated that they had been doing a ";Zoom meeting" however, there was no documentation of the meeting. d). A review of Patient 18's medical records indicated, the patient was admitted to HA on 11/17/22, with diagnoses for chronic obstructive pulmonary disease (COPD) and heart disease unspecified. A review of Patient 18's POC/IDG (plan of care/interdisciplinary group discussion) dated 11/17/22 indicated, "Spiritual – was informed of patient admission and will be calling the patient/family to schedule appointment for an initial chaplain visit. The Spiritual Care coordinator for spiritual assessment within 5 days of admission to identify spiritual needs/support for patient/family and primary caregiver. Psychosocial - MSW (Medical Social Worker) was informed of patient admission and will be calling the patient family to schedule an appointment for an initial MSW counselling and support. Evaluate and assess for initial evaluation within 5 days of admission for Psychosocial Counselling and support." Other/Physician – Volunteer Services are offered but are not needed at this time. Continue to offer Services. Certified Home health aide services are offered but are not needed at this time. Continue to offer services. The comprehensive assessment for the above IDGs was being done by an RN. There was no initial assessment by the MSW, Spiritual Counselling, MD, Bereavement and Volunteer documented in the clinical record as confirmed by not having an electronic signature. The IDG dated 11/23/22; 12/7/22; 12/21/22; and 1/4/23, was signed by an RN only. e). A review of Patient 19's electronic clinical record indicated a start of hospice care date of 9/27/22, with a terminal diagnosis of supraventricular tachycardia (a rapid heartbeat that develops when the normal electrical impulses of the heart are disrupted) and end stage renal disease (a medical condition in which kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of Patient 19s Plan of Care/Interdisciplinary Group review dated 10/12/22 and 1/4/23, indicated incomplete IDG signatures from IDG team attendees and no documented evidence of an evaluation of Patient 19s response to care, treatment, services provided and there was no progress toward desired outcome documented every 15 days. During an interview on 1/13/23, at 11:10 a.m., the Medical Social Worker (MSW) stated the last meeting she participated was on 11/4/22. The MSW stated she did not further participate because she was not invited by the agency to attend the meeting. f). A review of Patient 20s medical record indicated Patient 20 was admitted to the HA on 8/4/22, with diagnosis of chronic obstructive pulmonary disease (COPD, a chronic conditions in which the lungs are not working properly, causing shortness of breath). A review of Patient 20s clinical record titled, ";POC/IDG Review", dated 1/4/23; 12/21/22; 12/1/22; 11/23/22, 11/9/22, did not indicated the Chaplain had attended the IDG meeting. On 1/14/23, at 12:09 pm, during a telephone interview with the Medical Director (MD), he stated that he is not good with computers. He stated that he has given permission to the nurses to log in and sign under his name. He stated that he does not know how to log in and he does not know his username or password. He stated that if it is a requirement that he needs to log in to do it himself then he will learn how to do it. He stated that he has not logged in to the computer and he did not sign any IDGs in the Hospice MD. On 1/14/23, at 1:00 pm, during an interview with the Director of Patient Care Services (DPCS) stated the IDG members including, the registered nurse, doctor, social worker, and chaplain were required to attend the meetings, stated it was important to document the findings in the IDG meetings in the patients, record to know what the needs of the patient were and what information the group needs to know to follow up on.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation regarding IDG, Care Planning and Coordination of Services for patients was met as follows: --- 1.The Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG), in consultation with the patients physician prepared the written plan of care (POC) for one of six sampled patients (Patient 19). For Patient 19, the POC did not address Patient 19's peritoneal dialysis access (a catheter that is flexible, hollow tube about the size of a straw that's surgically placed in lower abdomen. A small piece of tubing is left outside of the body that can be covered when not in use) on his right abdominal area. There was no evidence the physician was consulted in the development of the plan of care. (Refer to L537). 2.The HA staff failed to provide care and services by not conducting weekly home visits by the licensed nurses as indicated in the patient's plan of care for two of six sampled patients (Patient 17 and Patient 18). (Refer to L543). 3. The HA failed to educate Responsible Party 1 (PR 1) of one of six sampled patients (Patient 19) regarding the comfort kit (small supply of medications kept at home available to rapidly treat symptoms that occur with terminal illness). (Refer to L544). 4. The HA failed to ensure current and accurate medications at home including comfort kit (small supply of medications kept at home available to rapidly treat symptoms that occur with terminal illness) were provided for two of six sampled patients (Patient 17 and Patient19). (Refer to L549). 5. The HA failed to ensure one of six sampled patients (Patient 18) had the medical equipment necessary to manage a patient's symptoms at home as indicated in the patient's plan of care. For Patient 18 who was assessed upon admission on 11/17/22 with respiratory dyspnea (shortness of breath upon walking) upon exertion, was not provided at home an oxygen concentrator (medical device that gives extra oxygen) and pulse oximeter (a test used to measure the oxygen level of the blood) as ordered by the physician. (Refer to L550). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated federal compliance to ensure the highest quality of care and services are provided to the patients under their care.

Based on record review and staff interview, the hospice agency failed to ensure the interdisciplinary group (IDG), in consultation with the patients physician, prepared the written plan of care (POC) for one of six sampled patients (Patient 19). For Patient 19, the POC did not address Patient 19's peritoneal dialysis access (a catheter that is flexible, hollow tube about the size of a straw that's surgically placed in lower abdomen. A small piece of tubing is left outside of the body that can be covered when not in use) on his right abdominal area. There was no evidence the physician was consulted in the development of the plan of care. This deficient practice could potentially prevent the patient from reaching their care planning goals. --- a. On 1/13/23, a review of Patient 19's electronic clinical record indicated a start of hospice care date of 9/27/22, with a terminal diagnoses of supraventricular tachycardia (is a rapid heartbeat that develops when the normal electrical impulses of the heart are disrupted) and end stage renal disease ( is a medical condition in which kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of the " Physician's Certification for Hospice Benefit" for the first 90- day period from 9/27/22 to 12/25/22, indicated Patient 19's terminal diagnoses were Supraventricular tachycardia and End stage renal disease. There was no documented evidence of interdisciplinary group meeting minutes. A review of Patients POC/Interdisciplinary group dated 10/12/22, 10/26/22, 11/9/22, 11/23/22, 12/7/22, 12/21/22 and 1/4/23, indicated no POC that addressed Patient 19s peritoneal dialysis access on his right abdominal area. There was no documented evidence the IDG prepared the POC in consultation with the physician, Medical Social Worker, Registered Nurse and chaplain participated in developing Patient 19's care plan. During an interview with the Director of Patient Care Services (DPCS) on 1/14/23, at 2:30 pm, DPCS stated the IDG should have discussed and formulated Patient 19s peritoneal dialysis access if it was assessed during the initial and comprehensive assessment. He stated that it is very important to address such issues like this in relation to individualized care planning. A review of the agency's undated policy and procedure titled, ";Interdisciplinary Group Meetings," stipulated, "the Interdisciplinary group would meet on a regular basis to discuss patient and family/caregiver changes in progress and update the plan of care, deaths and changes in the patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient's plan of care would be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. The meeting would be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members would be present, including volunteers and attending physicians, as available. The patient and family/caregiver would be informed of the schedule for this meeting, its purpose and that the discussion is confidential.

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Based on record review and staff interview, the hospice agency staff failed to provide care and services by not conducting weekly home visits by the licenses nurses as indicated on plan of care for two of six sampled patients (Patient 17 and Patient 18). This deficient practice had the potential for not meeting the patient needs that were identified in the plan of care that could impact the patient's health status and well being. --- a. A review Patient 17's record for the certification period date 10/11/22 through 1/8/23 indicated Patient 17, a 48 year old, who was admitted on 10/10/22 with diagnoses including acute ischemic heart disease. A review of Patient 17's plan of care indicated for a licensed vocational nurse (LVN) visit once a week plus 1 when needed; MSW one time visit and when needed; registered nurse (RN) visit 1-2 per week plus 1 as needed; Chaplain one time; Volunteer visit is as needed. A review of Patient17's electronic record indicated there was no weekly home visits by the LVN since the patient was admitted to the hospice agency on 10/10/22. A review of Patient 17's clinical visit notes dated 11/5/22 and 11/12/22, indicated the patient had declined the visits by the LVN. There was no documentation that Patient 17's decline for home visit was reported to the interdisciplinary team (IDT). During an interview on 1/14/23 at 10 a.m., the RN was unable to provide documentation regarding the weekly visits by the LVN. b. A review of Patient 18's record indicated Patient 18, a 65 years old, was admitted on 11/17/22, with admitting diagnoses including chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe) and heart disease unspecified. A review of Patient 18's record for the certification period of 11/17/22 through 2/14/23, indicated the plan of care included for certified home health aide (CHHA) visit once a week; Registered Nurse (RN) visit once a week; Medical Social Worker (MSW) visit once a week; Chaplain one time visit plus when needed; Volunteer once as needed, services offered but declined. A review of Patient 18's RN visit notes indicated visits were made on 12/1/22, 12/15/22 and 12/29/22 and not weekly as indicated in the patient's plan of care. There was no documentation of any discussion in the interdisciplinary group meeting regarding the RN visit every week was not being followed. During an interview on 1/14/23 at 10 a.m., the RN was not able to provide the documentation of the weekly visits by an RN. A review of the agency's policy and procedures on missed visits dated November 2020 indicated missed visits would be communicated in the IDG meeting, reasons for missed visits would be assessed, and IDG should evaluate the plan of care for appropriateness and make adjustments to the plan of care with input from the patient and Medical Director.

Based on interview and record review, the Hospice Agency (HA) failed to educate the patients Responsible Party 1 (PR 1) of one of six sampled patients (Patient 19) regarding the comfort kit (small supply of medications kept at home available to rapidly treat symptoms that occur with terminal illness). This deficient practice had the potential to result in the patient not to receive medications needed to achieve optimal quality of life. --- On 1/13/23, a review of Patient 19's electronic clinical record indicated a start of hospice care date of 9/27/22, with a terminal diagnoses of supraventricular tachycardia (is a rapid heartbeat that develops when the normal electrical impulses of the heart are disrupted) and end stage renal disease ( is a medical condition in which kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of Patient 19's "Plan of Care/Interdisciplinary Group Review," dated 10/12/22, 10/26/22, 11/9/22, 11/23/22, 12/7/22, 12/21/22 and 1/4/23, indicated no teaching was provided to Patient 19 and his family (PR 1) regarding use of comfort kit, side effects and adverse reactions of the medications. There was no documentation if comfort kit medications were explained to the patient and/or family member/caregiver. During an interview with PR 1 on 1/13/23 at 9:40 a.m., she stated the hospice agency did not provide teaching of comfort kit medications. She stated it was her first time seeing these medications and it was only delivered yesterday. She stated she does not know that Patient 19 was supposed to have this medication since his admission to hospice. During an interview with Director of Patient Care Services (DPCS) on 1/14/23 at 11:00 a.m., DPCS stated he was not aware there were no comfort kit provided to Patient 19. DPCS stated that skilled nurses (SN) should notify the hospice office if comfort kits are not available to patients and ensure that teaching was provided to patients/family members and caregivers prior to using the comfort kit and on each visit. A review of the HA's policy, titled "Comprehensive Assessment," revised in November 2020, indicated "During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record, including medications/equipment presently in home and potentially needed by patient and the care the family/caregiver is available, capable and willing to provide.

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Based on observation, interview and record review, the hospice agency failed to ensure current and accurate medications at home including comfort kit (small supply of medications kept at home available to rapidly treat symptoms that occur with terminal illness) were provided for two of 6 sampled patients (Patient 17 and Patient19) . This deficient practice had the potential for the patients not receiving medication regimen during the end-of-life experience. --- a. A review of Patient 17's record indicated Patient 17, a 48 years old, was admitted on 10/11/22, with diagnosis of acute ischemic heart disease (conditions associated with sudden, reduced blood flow to the heart). A review of Patient 17's Comprehensive Nursing Assessment dated 10/11/22 indicated the pain screening included the patient was uncomfortable because of pain. Patient 17 complained of pain in right arm, right let, and fingers were numb with a pain scale of 7 out of 10, and 10 being the worst pain. Further review of the notes, patient's pain was relieved with acupuncture and message, but no improvement. There was no documentation, the agency provided a pain management for the patient. A review of Patient 17's Current Treatment/Medication DME (durable medical equipment) List indicated an order dated 10/11/22 for comfort kit medications as follows: Levsin 0.125 mg/ml drops 1 ml sublingual every four hours as needed for excessive secretions Bisacodyl 10 mg rectal suppository I suppository daily as needed for constipation Acetaminophen 650 mg / rectal I suppository per rectum every four hours as needed for mild pain/fever Lorazepam 2 mg/ml concentrate solution 0.25 mg ml sublingual every four hours as needed for anxiety/anxiety Morphine Sulfate 20 mg/ml 0.25 ml sublingual every 2 hours as needed for severe pain/shortness of breath Prochlorperazine 25 mg rectal suppository I suppository every 12 hours as needed for nausea/vomiting. On 1/13/23, at 10 a.m., during the home visit in Patient 17's residence with the Director of Patient Care Services (DPCS), Patient 17 was not available. During a concurrent interview, Patient 17's roommate (Patient 18) stated Patient 17 was out for an appointment. Patient 17's roommate stated Patient 17 was aware of the home visit but she needed to go for an appointment and left her medication bottles to be checked. When asked for Patient 17 for the rest of her medications, the DPCS stated there were only three bottles as follows: Lisinopril (medication used to treat high blood pressure) 20 milligrams (mg) one tablet daily; Amlodipine (medication used to lower blood pressure) 5 mg one tablet every evening and Docusate Sodium (stool softener)100 mg daily ay bedtime as needed. The following medications were not available: Atorvastatin (medication to help lower bad cholesterol) 20 mg daily and Patient 17's comfort kit medications as indicated in Patient 17's Current Treatment/Medication DME (durable medical equipment) List with an order date of 10/11/22. A review of the pharmacy receipt indicated the comfort kit was delivered to the patient's residence on 1/12/23 6 p.m. On 1/14/23, at 10 a.m., during an interview, the registered nurse (RN) stated that Patient 17s comfort kit was in the refrigerator and her roommate did not show to the surveyor. The RN stated Patient 17s comfort kit was just delivered on 1/12/23, instead of being delivered when the patient was admitted on 10/11/22. b. On 1/13/23, a review of Patient 19's electronic clinical record indicated a start of hospice care date of 9/27/22, with a terminal diagnoses of supraventricular tachycardia (is a rapid heartbeat that develops when the normal electrical impulses of the heart are disrupted) and end stage renal disease ( is a medical condition in which kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 1/4/23, indicated skilled nurse (SN) visit once a week on current recertification period from 12/26/22 to 3/25/23. During a joint home visit with the Director of Patient Care Services on 1/13/23, at 11:30 a.m., Patient 19 was observed awake alert and oriented, resting on his bed comfortably. DPCS performed hand washing prior to conduct an assessment with Patient 19. While conducting a medication reconciliation with DPCS, Patient 19s family member stated that comfort kit medications were delivered yesterday (1/12/23) and according to her, it was the first time that the hospice agency provided a comfort kit medications to Patient 19. Patient 19s wife stated they never have the comfort kit since her husband was admitted on 9/27/22 to the hospice program. During a concurrent interview, DPCS stated that SN should conduct medication reconciliation on each visit to ensure that medications are appropriately provided to patients. DPCS stated that it is important for patients to have a comfort kit medication ready at home for immediate use if patients condition started to decline. A review of Patient 19's record indicated there was no documented evidence the comfort kit was provided to Patient 19 prior to 1/12/23 (one day prior to surveyor visit on 1/13/23). When asked for a policy on the use of Comfort Kit on 1/13/23 at 11:30 a.m., the DPCS did not provide one.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure one of six sampled patients (Patient 18) had the medical equipment necessary to manage a patient's symptoms at home as indicated in the patient's plan of care. For Patient 18 who was assessed upon admission on 11/17/22 with respiratory dyspnea (shortness of breath upon walking) upon exertion, was not provided at home an oxygen concentrator (medical device that gives extra oxygen) and pulse oximeter (a test used to measure the oxygen level of the blood) as ordered by the physician. This failure had the potential for the patient not receiving oxygen as needed for respiratory difficulty and had the potential to result in respiratory distress. --- A review of Patient 18's record indicated Patient 18, a 65 years old, was admitted on 11/17/22, with admitting diagnoses including chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe) and heart disease unspecified. A review of Patient 18s clinical record titled, ";POC Summary," for certification period 10/11/22-1/8/23 indicated, ";...11. DME (durable medical equipment)...Order date 10/31/22 Oxygen Concentrator 5L (stationary)...Order date 10/13/22 pulse oximeter". A review of Patient 18s clinical record titled, ";Comprehensive Nursing Assessment", dated 10/11/22, indicated, ";...Respiratory dyspnea (shortness of breath upon walking) mild, exertion level with mild exertion...". On 1/14/23, at 10 a.m., during a home visit at Patient 18s residence, she was observed to be alert, oriented but speaks foreign language only. Patient 18 was able to understand by gestures. Patient 18 invited the surveyor to go to her room. Patient 18 was able to ambulate in slow steady gait. Patient 18 tried to call her neighbor to interpret but she was not available. However, Patient 18 has a voice activated machine that can interpret the conversation. During an observation of the medical equipment at home, it was noted Patient 18 did not have an oxygen concentrator and a pulse oximeter. During an interview on 1/14/23, at 11:00 a.m., with Patient 18, she stated she wanted a machine to help her breathe better. During an interview on 1/14/23, at 11:00 a.m., Registered Nurse 1 (RN 1) stated he did not know why the oxygen concentrator and pulse oximeter were not at Patient 18s home and stated she should have the equipment.

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Based on interview and record review, the hospice agency failed to ensure the Condition of Participations for Clinical Records were met as follows: --- 1.The hospice agency failed to ensure the contents of the Clinical Records were protected from any modifications (making partial or minor changes) from unauthorized personnel for 6 of six sampled patients, (Patients 4, 13, 17, 18, 19, and 20).This failure had the potential for the clinical records to contain false and inaccurate documents which can affect the formulation of patients plan of care, interventions, and can affect the quality of care and services provided by the agency to all the patients under their care. (Refer to L679). 2.The Hospice Agency (HA) failed to ensure, 6 of six sampled patients (Patients 4, 13, 17, 18, 19, and 20), the Clinical records were not intentionally accessed to enter clinical notes by staffs not directly involved in providing patient care and services. Interdisciplinary group notes were signed by an unknown user. This deficient practice violated the patients rights to privacy and confidentiality and had the potential that false and incorrect information were entered in the clinical records that can potentially affect the care planning process and interventions formulated for the care of the affected patients and can affect the quality of care and services provided to the affected patients. (Refer to L680). The cumulative effect of these systemic problems resulted in the hospice agencys inability to ensure provision of quality health care in a safe environment.

Based on interview and record review, the hospice agency failed to ensure the contents of the Clinical Records were protected from any modifications (making partial or minor changes) from unauthorized personnel for 6 of six sampled patients, (Patients 4, 13, 17, 18, 19, and 20). This failure had the potential for the clinical records to contain false and inaccurate documents which can affect the formulation of patients plan of care, interventions, and can affect the quality of care and services provided by the agency to all the patients under their care. --- a). A review of Patient 4s clinical record indicated Patient 4 was a 77-year-old female admitted to the Hospice Agency (HA) on 6/1/22, with a diagnosis of heart failure (a chronic condition in which the heart doesnt pump blood as well as it should). A review of Patient 4s clinical records titled, ";POC/IDG Review", dated 1/4/23; 12/21/22; 12/7/22; 11/23/22;11/9/22, did not indicate authentication from the doctor, registered nurse, medical social worker, and chaplain. Further review of these records did not indicate notes for section titled ";IDG discussion/updated Comprehensive Assessment Review". The electronic medical record for Patient 4, titled ";Audit Log" (a document that records events in an information technology/IT system, documents what resources were accessed, and entries that include patients name, modification date, a timestamp and user login information), dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. Multiple entries for Interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), and signatures for IDG were added between 1/12/23 from 2:03 p.m. to 1/13/22 at 10:02 a.m., after the California Department of Public Health surveyors (CDPH, government employee who conducts health facilities inspections) entered the HA. Further review of the record indicated Registered Nurse 1 (RN 1) had entered multiple entries in the modules titled, ";IDG". b). On 1/13/23, a review of Patient 13's electronic clinical record indicated a start of hospice care date of 5/18/22, with a terminal diagnosis of atherosclerosis heart disease of native coronary artery (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow), with unspecified angina pectoris (chest pain or discomfort). The electronic medical record for Patient 13, titled ";Audit Log", dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. Multiple entries for Interdisciplinary group and signatures for IDG were added between 1/12/23 from 11:10 a.m. to 1/13/22 at 5:14 a.m., after CDPH entered the HA. Further review of the record indicated Registered Nurse 1 (RN 1) had entered multiple entries in the modules titled, ";IDG". c). A review of Patient 17s clinical record indicated Patient 17, a 48 year old, female with diagnoses taken as Acute ischemic heart disease was admitted on 10/10/22. During the first certification period date of 10/11/22 through 1/8/23. A review of Patient 17s clinical records titled, ";POC/IDG Review", dated 1/4/23; 12/21/22; 12/7/22; 11/23/22;11/9/22, did not indicate authentication from the doctor, registered nurse, medical social worker, and chaplain. Further review of these records did not indicate notes for section titled ";IDG discussion/updated Comprehensive Assessment Review". The electronic medical record for Patient 17, titled ";Audit Log", dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. Multiple entries for Interdisciplinary group and signatures for IDG were added between 1/12/23 from 1:16 p.m. to 1/13/22 at 5:01 a.m., after CDPH entered the HA. Further review of the record indicated Registered Nurse 1 (RN 1) had entered multiple entries in the modules titled, ";IDG". d). A review of Patient 18s clinical record indicated Patient 18, a 48 year old, female with diagnoses taken as Acute ischemic heart disease was admitted on 10/10/22. During the first certification period date of 10/11/22 through 1/8/23. A review of Patient 18s clinical records titled, ";POC/IDG Review", dated 1/4/23; 12/21/22; 12/7/22; 11/23/22; and 11/17/22, did not indicate authentication from the doctor, registered nurse, medical social worker, and chaplain. Further review of these records did not indicate notes for section titled ";IDG discussion/updated Comprehensive Assessment Review". The electronic medical record for Patient 18, titled ";Audit Log", dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. Multiple entries for Interdisciplinary group and signatures for IDG were added between 1/12/23 from 12:41 p.m. to 1/13/22 at 5:03 a.m., after CDPH entered the HA. Further review of the record indicated Registered Nurse 1 (RN 1) had entered multiple entries in the modules titled, ";IDG". e). On 1/13/23, a review of Patient 19's electronic clinical record indicated a start of hospice care date of 9/27/22, with a terminal diagnosis of supraventricular tachycardia (is a rapid heartbeat that develops when the normal electrical impulses of the heart are disrupted) and end stage renal disease ( is a medical condition in which kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). A review of Patient 19s clinical records titled, ";POC/IDG Review", dated 1/4/23, did not indicate authentication from the doctor, registered nurse, medical social worker, and chaplain. Further review of these records did not indicate notes for section titled ";IDG discussion/updated Comprehensive Assessment Review". The electronic medical record for Patient 19, titled ";Audit Log", dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. Multiple entries for Interdisciplinary group and signatures for IDG were added between 1/12/23 from 4:24 p.m. to 1/13/22 at 4:59 a.m., after CDPH entered the HA. Further review of the record indicated Registered Nurse 1 (RN 1) had entered multiple entries in the modules titled, ";IDG". f). A review of Patient 20s clinical record indicated Patient 20 was a 56-year-old male admitted to the HA on 8/4/22, with diagnosis of chronic obstructive pulmonary disease (a chronic conditions in which the lungs are not working properly, causing shortness of breath). The electronic medical record for Patient 20, titled, ";Audit Log" dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. The ";Audit Log" for Patient 20 indicated multiple entries for Interdisciplinary group and signatures for IDG were added between 1/12/23 from 5:18 p.m. to 1/13/22 at 4:57 a.m., after the California Department of Public Health surveyors (CDPH, government employee who conducts health facilities inspections) entered the HA. Further review of the record indicated Registered Nurse 1 (RN 1) had entered multiple entries in the modules titled, ";IDG". During an interview on 1/13/23, at 11:10 a.m., the MSW (Medical Social Worker) stated it was expected to go into the electronic medical record, the same day the IDG meeting is held, to sign she had attended the meeting. The MSW stated she did not routinely document her input in the IDG meeting in the patients electronic medical record unless she was taking care of them. The MSW stated the last time she attended an IDG meeting was on 11/4/22. During an interview on 1/13/23, at 2:10 p.m., Registered Nurse 1 (RN 1) stated the IDG disciplines were supposed to go in and document their own notes in the medical record. RN 1 stated he entered notes for the disciplines because he is the clinical supervisor and he had to make sure they were entered. RN 1 stated ";no, we are not supposed to document for others. But they (IDG disciplines) review the documentation" and sign it. A review of the Hospice Agencys Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 1/9/23, indicated, ";L679...A staff in-service was made with State and Federal Regulations...All entries must be legible, clear, complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice...The hospice agency will take appropriate steps to protect the integrity of ePHI that it creates, receives, maintains, or transmits from unauthorized modification. Finally, an in-service provided to clinical staff focused on appropriate steps to ensured that workforce members are provided training and awareness about the authentication methods used and all clinical records were not modified..." During the revisit survey, the agency did not provide evidence of in-services conducted as specified in the Plan of Correction.

Based on interview and record review, the Hospice Agency (HA) failed to ensure, 6 of six sampled patients (Patients 4, 13, 17, 18, 19, and 20), the Clinical records were not intentionally accessed to enter clinical notes by staffs not directly involved in providing patient care and services. Interdisciplinary group notes were signed by an unknown user. This deficient practice violated the patients rights to privacy and confidentiality and had the potential that false and incorrect information were entered in the clinical records that can potentially affect the care planning process and interventions formulated for the care of the affected patients and can affect the quality of care and services provided to the affected patients. --- a). A review of Patient 4s clinical record indicated Patient 4 was a 77-year-old female admitted to the Hospice Agency (HA) on 6/1/22, with a diagnosis of heart failure (a chronic condition in which the heart doesnt pump blood as well as it should). A review of Patient 4s clinical records titled, ";POC/IDG Review", dated 1/4/23; 12/21/22; 12/7/22; 11/23/22;11/9/22, did not indicate authentication from the doctor, registered nurse, medical social worker, and chaplain. The electronic medical record for Patient 4, titled ";Audit Log" (a document that records events in an information technology/IT system, documents what resources were accessed, and entries that include patients name, modification date, a timestamp and user login information), dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. The record indicated the Medical Social Worker (MSW) accessed Patient 4s module titled ";IDG" on 1/13/23 between 4:40 a.m. to 4:43 a.m., and signed the notes for dates 1/4/23, 12/21/22, 12/7/22, 11/23/22, and 11/9/22. The electronic medical record for Patient 4, titled ";Audit Log" dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. The record indicated the Medical Doctor (MD) accessed Patient 4s module titled ";IDG" on 1/13/23 between 4:33 a.m. to 4:34 a.m., and signed the notes for dates 1/4/23, 12/21/22, 12/7/22, 11/23/22, and 11/9/22. b). On 1/13/23, a review of Patient 13's electronic clinical record indicated a start of hospice care date of 5/18/22, with a terminal diagnosis of atherosclerosis heart disease of native coronary artery (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow), with unspecified angina pectoris (chest pain or discomfort). The electronic medical record for Patient 13, titled ";Audit Log" dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. The record indicated the MSW accessed Patient 13s module titled ";IDG" on 1/13/23 at 5:08 a.m. and signed the notes for dates 12/7/22, 11/23/22, and 11/9/22. The electronic medical record for Patient 13, titled ";Audit Log" dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. The record indicated MD accessed Patient 13s module titled ";IDG" on 1/13/23 at 5:14 a.m., and signed the notes for dates 12/7/22, 11/23/22, and 11/9/22. c). A review of Patient 17s clinical records titled, ";POC/IDG Review", dated 1/4/23; 12/21/22; 12/7/22; 11/23/22;11/9/22, did not indicate authentication from the doctor, registered nurse, medical social worker, and chaplain. The electronic medical record for Patient 17, titled ";Audit Log" dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. The record indicated the MSW accessed Patient 17s module titled ";IDG" on 1/13/23 between 5:00 a.m. and 5:01 a.m., and signed the notes for dates 1/4/23, 12/21/22, 12/7/22, 11/23/22, and 11/9/22. The electronic medical record for Patient 17, titled ";Audit Log" dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. The record indicated the MD accessed Patient 17s module titled ";IDG" 1/13/23 between 3:51 a.m. and 4:48 a.m.., and signed the notes for dates 1/4/23, 12/21/22, 12/7/22, 11/23/22, and 11/9/22. d). A review of Patient 18s clinical records titled, ";POC/IDG Review", dated 1/4/23; 12/21/22; 12/7/22; 11/23/22;11/17/22, did not indicate authentication from the doctor, registered nurse, medical social worker, and chaplain. The electronic medical record for Patient 18, titled ";Audit Log" dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. The record indicated the MSW accessed Patient 18s module titled ";IDG" on 1/13/23 between 5:02 a.m. and 5:03 a.m., and signed the notes for dates 1/4/23, 12/21/22, 12/7/22, 11/23/22, and 11/17/22. The electronic medical record for Patient 18, titled ";Audit Log" dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. The record indicated the MD accessed Patient 18s module titled ";IDG" 1/13/23 between 3:39 a.m. and 3:41 a.m.., and signed the notes for dates 1/4/23, 12/21/22, 12/7/22, 11/23/22, and 11/17/22. e). A review of Patient 19s clinical records titled, ";POC/IDG Review", dated 1/4/23, did not indicate authentication from the doctor, registered nurse, medical social worker, and chaplain. The electronic medical record for Patient 19, titled ";Audit Log", dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. The record indicated the MSW accessed Patient 19s module titled ";IDG" on 1/13/23 between 4:58 a.m. and 4:59 a.m., and signed the notes for dates 1/4/23, 12/21/22, 12/7/22, 11/23/22, and 11/9/22. The electronic medical record for Patient 19, titled ";Audit Log" dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. The record indicated the MD accessed Patient 19s module titled ";IDG" 1/13/23 between 4:37 a.m. and 4:41 a.m.., and signed the notes for dates 1/4/23, 12/21/22, 12/7/22, 11/23/22, and 11/9/22. f). A review of Patient 20s clinical record indicated Patient 20 was a 56-year-old male admitted to the HA on 8/4/22, with diagnosis of chronic obstructive pulmonary disease (a chronic conditions in which the lungs are not working properly, causing shortness of breath). The electronic medical record for Patient 20, titled ";Audit Log", dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. The record indicated the MSW accessed Patient 20s module titled ";IDG" on 1/13/23 between 4:19 a.m. and 4:21 a.m., and signed the notes for dates 1/4/23, 12/21/22, 12/7/22, 11/23/22, and 11/9/22. The electronic medical record for Patient 20, titled ";Audit Log" dated 1/11/23 to 1/13/23 were reviewed and indicated the clinical records were modified. The record indicated the MD accessed Patient 20s module titled ";IDG" 1/13/23 between 4:11 a.m. and 4:13 a.m.., and signed the notes for dates 1/4/23, 12/21/22, 12/7/22, 11/23/22, and 11/9/22. During an interview on 1/13/23, at 11:10 a.m., the MSW stated it was expected to go into the electronic medical record, the same day the IDG meeting is held, to sign she had attended the meeting. The MSW stated, ";No, I did not log in 1/13/23 to sign IDG documents. I am at work today. No, I did not log in 1/13/23 to sign for an IDG meeting on 1/4/23. No, I did not log in 1/13/23 to sign for an IDG meeting on 12/21/22. No, I did not log in 1/13/23 to sign for an IDG meeting on 12/7/22. No, I did not log in 1/13/23 to sign for an IDG meeting on 11/23/22. No, I did not log in 1/13/23 to sign for an IDG meeting on 11/9/22." The MSW stated she had not shared her username and password or given permission to anyone to use her username and password to log into the electronic medical record. The MSW stated the last time she attended an IDG meeting was on 11/4/22. During an interview on 1/14/23, at 12:09 p.m., the MD stated he did not know how to log into the electronic medical record to sign documents. The MD stated he did not know his username and password. The MD stated he gave permission to the nurses at the agency to log in and sign documents in his name. The MD stated he did not log in to the record to sign IDG notes. The MD stated, ";Im telling you, I have not logged in to the computer. No, I did not sign any IDGs in the computer." During an interview on 1/14/23, at 12:40 p.m., Registered Nurse 1 (RN 1) stated he did not know who is signing on to the electronic medical record to sign for the MDs behalf. A review of the Hospice Agencys Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 1/9/23, indicated, ";L680...A staff in-service was made with State and Federal Regulations...Agency must ensure that the Clinical records were not accessible by staffs that not directly involved in providing patient care and services...Next, instructed clinical staff that only authorized personnel will have access to the clinical/service and financial records...Finally, an in-service provided to clinical staff focused on ensuring clinical records, its contents and the information contained therein must be safeguarded against loss or unauthorized use..." During the revisit survey, the agency did not provide evidence of in-services conducted as specified in the Plan of Correction.

Based on interview and record review, the Hospice Agency failed to notify the local licensing department regarding change of address within 10 days of the change. This deficient practice resulted in the agency's not notifying the Department of the current changes of their operational status that could lead to the public misinformation. --- During an interview on 1/13/23, at 10:00 a.m., Staff 1 stated the agency moved to the new location ";last days" of December 2022. During an interview on 1/13/23, at 2:00 p.m., Registered Nurse 1 stated he did not remember when the agency moved to its new location. RN 1 stated he did not know the date of when the local licensing department was notified. During an interview on 1/14/23, at 10:56 a.m., RN 1 stated he did not have evidence the agency had informed the local licensing department regarding the address change. A review of the Hospice Agencys Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by stated field staff), dated 1/9/23, indicated, ";L798...A staff in-service was made with State and Federal Regulations...The hospice and its staff must operate and furnish services in compliance with all applicable Federal, State, and local laws and regulations related to the health and safety of patients..." During the revisit survey, the agency did not provide evidence of in-services conducted as specified in the Plan of Correction.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Initial and Comprehensive Assessment of Patients was met as follows: 1. The hospice agency failed to ensure the medications listed in the medication profile matches the current home medications for two of 6 sampled patients, Patient 13 and Patient 16. This had the potential for medication errors and adverse drug reactions which can affect the health and safety of the affected patients. (Refer to L530). 2. The hospice agency failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) were conducted, and the comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) were updated at least every 15 days for the five of six sampled patients, (Patients 4, 13, 14, 15, and 16). This can result to the needs and concerns of the affected patients are not addressed, goals will not be achieved, which can affect the highest practicable mental, physical, and psychosocial well-being of the patients under the agency's care. (Refer to L533). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated federal compliance to ensure safety and the highest quality care and services are provided to the patients under their care. --- .

Based on observation, interview, and record review, the hospice agency failed to ensure the medications listed in the medication profile matches the current home medications for two of 6 sampled patients, Patient 13 and 16. This failure had the potential for medication errors and adverse drug reactions which can affect the health and safety of the affected patients. --- a. A review of Patient 13s profile, indicated a start of care date (SOC) to the Hospice Agency on 5/18/22, with diagnoses that included atherosclerosis heart disease (buildup of fats, cholesterol, and other substances in and on the artery walls). During a home visit observation on 9/30/2022, at 1:30 p.m., the Director of Patient Care Services (DPCS) was observed providing care to Patient 13. On 9/30/2022, at 1:45 p.m., during another concurrent observation and interview, the DPCS was observed reviewing the medications Patient 13 was taking. Patient 13 stated he was taking the following medications: a). Ibuprofen (pain medication) 200 mg (unit of measurement) tablets as needed for pain. b). Dolo-Neurobion, a medication obtained from Tijuana Mexico. Patient 13 stated this medication was considered a vitamin, and he took them to help him feel less tired. When asked, the DPCS stated Ibuprofen and Dolo-Neurobion, were not listed on the medication profile. On 9/30/2022, at 1:50 p.m., during an interview, the DPCS stated the following medications listed on the profile were not at Patient 13s home: a). Comfort kit (a group of medications used at the end of life to lessen symptoms). b). Acetaminophen (pain medicine) 650 mg (milligrams) suppository (administration via rectum). c). Lorazepam (anxiety medication) 0.25 ml (milliliter) sublingual (under the tongue). d). Morphine Sulfate (pain medicine) 0.25 ml sublingual. e). Prochlorperazine (to treat nausea) 25 mg 1 suppository. f). Levsin (medicinefor excessive secretions) 1 ml sublingual. G). g). Bisacodyl (stool softener) 10 mg 1 suppository. When asked, Patient 13 stated he never had the comfort kit medications at his home. The DPCS stated it is important to have all the medications the patient takes as listed on the medication profile to ensure medications are taken safely. The DPCS stated he would follow up with the pharmacy to ensure Patient 13 had his medications at home. A review of the Hospice Agencys CMS 2567 (Centers for Medicare and Medicaid Services, official report of deficiencies after a survey) report for the recertification survey 7/19/2022 with the Plan of Correction (a document describing how the agency will correct the deficient practice found during the recertification survey), dated 9/22/22, indicated at ";L 530...The comprehensive assessment must take into consideration the following factors: (6) Drug profile. A review of all the patients prescription and over-the counter drugs, herbal remedies and other alternative treatments that could affect drug therapy. Educate the staff regarding the medical records documentations, admission forms to ensure all the required medications are present. Also, an in-service was made to the staff regarding the facility policy based on Medication profile. Supervisory visit was done by RN (registered nurse) ensuring that medication profiles were updated for each change to reflect current medications, new and/or discontinued medications..." b. A review of Patient 16s clinical record indicated Patient 16 was admitted to the Hospice Agency (HA) on 8/16/2022, with a diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure. On 9/30/2022 at 11:30 a.m., during a joint home visit with Director of Patient Care Services (DPCS), a medication review was conducted. Upon medication review with the DPCS, it was observed that Omega 3 Ethyl Ester 1 Gram, one Capsule by mouth twice daily, was not included in Patient 16s medication profile. Patient 16's medication profile also listed a ";Comfort Kit" (a Hospice Emergency Kit or E-Kit, that contains a small supply of medications kept in the home so that they will be available to rapidly treat symptoms that may occur in a patient with a terminal illness), however this was not provided by the HA. The comfort kit lists included the following medications: 1). Acetaminophen 650 Mg rectal suppository, 1 suppository every four hours as needed. 2). Bisacodyl 10 Mg rectal suppository, one suppository daily as needed. 3). Levsin 0.125 Mg/mL. drops, 1 mL. sublingual every four hours as needed. 4). Lorazepam 2 Mg/mL. concentrate solution, 0.25 mL. sublingual every four hours as needed. 5). Morphine Sulfate 20 Mg/mL., 0.25 mL. sublingual every four hours as needed. 6). Prochlorperazine 25 Mg. rectal suppository, one suppository every 12 hours as needed. On 9/30/2022 at 11:40 a.m., during an interview with Family Member 1 (FM 1), who acted as a caregiver for Patient 16, FM 1 stated there was no comfort kit in the house. FM1 stated she did not know what a comfort kit was, and nobody from the HA had explained or talked about a comfort kit. During an interview with DPCS on 9/30/2022 at 11:30 a.m., DPCS stated all medications taken by Patient 16 needed to be included in the medication profile. DPCS stated it was important to have an updated medication profile so the HA could assess the effectiveness of medications, the side effects, or if there were interactions with other drugs. DPCS stated an updated medication profile would allow the HA staff to better educate the patient and the caregiver. A review of the HAs policy, titled ";Contents of the Clinical Record," revised in November 2020, indicated a current medication profile included prescription and nonprescription medications, herbal products, and home remedies; dose, frequency, and route of administration; with ongoing updates to the patients medication regimen, including new, changed, and discontinued medications, adverse reactions, significant side effects, drug allergies, and contraindications."

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Based on observation, interview and record review, the agency failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) were conducted, and the comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) were updated at least every 15 days for the five of six sampled patients, (Patients 4, 13, 14, 15, and 16). This deficient practice had the potential that the needs and concerns of the affected patients will not be addressed, goals will not be achieved, which can affect the highest practicable mental, physical, and psychosocial well-being of the patients under the agency's care. --- a). A review of Patient 4s clinical record indicated Patient 4 was a 77-year-old female admitted to the Hospice Agency (HA) on 6/1/2022, with a diagnosis of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). A review of Patient 4s ";POC/IDG Review" [Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/Interdisciplinary Group (team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities)] did not indicate the physician (MD), Director of Patient Care Services (DPCS)/Registered Nurse (RN), and Social Worker (SW) had participated in the IDG meetings on 8/3/2022 and 8/17/2022. The signature spaces for MD, DPCS/RN, and SW were left blank. The ";POC/IDG Review" form dated 8/24/2022 did not have the signatures of the DPCS/RN and the SW. Patient 4 did not have any ";POC/IDG Review" conducted after 8/24/2022 as of 9/29/2022. b). A review of Patient 13s profile, indicated a start of care date to the Hospice Agency (HA) on 5/18/22, with diagnoses that included atherosclerosis heart disease (buildup of fats, cholesterol, and other substances in and on the artery walls). A review of Patient 13s record titled, POC/IDG Review, dated 8/3/22, did not indicate a registered nurse and the medical social worker attended the meeting. A review of Patient 13s record titled, POC/IDG Review, dated 8/17/22, did not indicate the doctor, registered nurse and the medical social worker attended the meeting. Continued review of Patient 13s electronic medical records did not indicate the IDG group met at least every 15 days to discuss Patient 13s care. c). A review of Patient 4s clinical record indicated Patient 4 was a 77-year-old female admitted to the Hospice Agency (HA) on 6/1/2022, with a diagnosis of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), unspecified. A review of Patient 4s ";POC/IDG Review" (Plan of Care/Interdisciplinary Group) did not indicate the MD, DPCS/Registered Nurse (RN), and Social Worker (SW) had participated in the IDG meetings on 8/3/2022 and 8/17/2022. The signature spaces for MD, DPCS/RN, and SW were left blank. Signatures for DPCS/RN and SW were missing on ";POC/IDG Review" dated 8/24/2022, indicating DPCS/RN and SW had not attended. Patient 4 did not have any ";POC/IDG Review" after 8/24/2022 as of 9/29/2022. d). A review of Patient 14s profile indicates a start of care date to the Hospice Agency on 4/25/22, with diagnoses including Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 14s record titled, POC/IDG Review, dated 8/3/22, did not indicate the doctor, registered nurse, medical social worker, and spiritual counselor attended the meeting. A review of Patient 14s record titled, POC/IDG Review, dated 8/17/22, did not indicate a doctor, medical social worker, and spiritual counselor attended the meeting. Continued review of Patient 14s electronic medical records did not indicate the IDG group met at least every 15 days to discuss Patient 14s care. d). A review of Patient 15s profile indicated a start of care date to the Hospice Agency on 4/26/22 with diagnoses including heart disease. A review of Patient 15s record titled, POC/IDG Review, dated 8/3/22, did not indicate the doctor, registered nurse, and medical social worker, attended the meeting. A review of Patient 15s record titled, POC/IDG Review, dated 8/17/22, did not indicate the doctor, registered nurse, and medical social worker, attended the meeting. A review of Patient 15s record titled, POC/IDG Review, dated 8/31/22, did not indicate the doctor, registered nurse, and medical social worker, attended the meeting. Continued review of Patient 15s electronic medical records did not indicate the IDG group met at least every 15 days to discuss Patient 15s care. e). A review of Patient 16s clinical record indicated Patient 16 was a 69-year-old male admitted to the Hospice Agency (HA) on 8/16/2022, with a diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure. A review of Patient 16s ";POC/IDG Review" (Plan of Care/Interdisciplinary Group) did not indicate the physician (MD), DPCS/Registered Nurse (RN), and Social Worker (SW) had participated in the IDG meeting on 8/16/2022. The signature spaces for MD, DPCS/RN, and SW were left blank. Patient 16 did not have any ";POC/IDG Review" after 8/16/2022 as of 9/29/2022. During an interview with DPCS on 10/3/2022 at 12:09 p.m., DPCS stated the MD, DPCS/RN, SW, and SC were members of the IDG and were required to attend IDG meetings. IDG meetings were mostly conducted on Zoom, although he always attended in-person. DPCS stated the IDG meetings were done every Wednesday and the HA would send out a sign-in sheet for the IDG members to sign and return to the HA. DPCS stated there was no time frame as to when the IDG members needed to return the signed sign-in sheet back. DPCS stated, ";I have to make a policy for that." A review of the HAs document, titled ";IDT Attendance Sheet," indicated the HA only took attendance on IDG meetings held on 8/31/2022, 9/14/2022, and 9/28/2022. IDT Attendance Sheet on those dates were signed by the MD, DPCS, RN, SW, and SC. A review of facility's policy titled, "Interdisciplinary Group (IDG) Meeting," revised November 2020, indicated, "The IDG will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care. Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. It also indicated, the hospice Medical Director and all hospice IDG members will be present. The members at the IDG meeting will sign an attendance form." During an interview on 10/3/22, at 12:09 p.m. the Director of Patient Care Services (DPCS) stated the IDG members including, the registered nurse, doctor, social worker, and chaplain were required to attend the meetings. During an interview on 10/3/22, at 12:40 p.m., the DPCS stated it was important to document the findings in the IDG meetings in the patients record to know what the needs of the patient were and what information the group needs to know to follow up on. A review of the Hospice Agencys Plan of Correction (a document describing how the agency will correct the deficient practice found during the recertification survey), dated 9/22/22, indicated, ";L 533...It must include information on the patients progress toward desired outcomes, as well as a reassessment of the patients response to care. The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days. Educated the staff that based on the facilitys policy titled ";Interdisciplinary Group (IDG) Meeting, it is a requirement that the interdisciplinary group will meet on a regular basis to discuss patient and family/ caregiver changes and progress and updates to the plan of care, deaths and changes in patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment, no less frequently than every 15 days or more frequently if the patient's condition requires. Also, an in-service was performed focusing on the signing of the IDG meeting attendance of all the interdisciplinary group members to be kept by the Clinical Supervisor."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation regarding IDG, Care Planning and Coordination of Services for patients was met as follows: 1.The Hospice Agency (HA) failed to ensure the care and services follow the individualized plan of care regarding frequency of home visits by the licensed nurses and hospice aide for three of six sampled patients (Patient 12, 14, and 15). (Refer to L543) 2.The the Hospice Agency (HA) failed to educate Family Member 1 (FM 1) of one of six sampled patients (Patient 16) regarding the comfort kit (medications used to alleviate symptoms during the end-of-life process) and volunteer services. (Refer to L544) 3. The HA failed to ensure the comfort kit (medications used to alleviate symptoms during the end-of-life process) was available for two of six sampled patients (Patient 13 and 16). (Refer to L 550) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated federal compliance to ensure the highest quality of care and services are provided to the patients under their care. --- .

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Based on interview and record review, the Hospice Agency (HA) failed to ensure the care and services follow the individualized plan of care regarding frequency of home visits by the licensed nurses and hospice aide for three of six sampled patients (Patient 12, 14, and 15). This deficient practice resulted in the patients not receiving home visits from the agency staff which had the potential for not identifying a change in the patients condition and the care needs of the patients. --- a. A review of Patient 12s clinical record indicated Patient 12, a 51-year-old female, was admitted to the hospice agency on 8/16/2022, with a diagnosis of chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems) with acute exacerbation (worsening of preexisting symptoms in patient). A review of Patient 12s ";POC/IDG Review," dated 8/29/2022, 9/14/2022, and 9/28/2022, indicated the frequency of visits as follows: 1). Hospice Aide 2 per week, 2). Licensed Vocational Nurse (LVN) 1 per week + 1 as needed visits, 3). Social Worker (SW) 1 per month + 1 as needed visit, 4). Registered Nurse (RN) 1 per 2 weeks + 1 as needed visit, 5). Pastor (SC) one time then as needed. A review of Patient 12s ";History of HA (Hospice Aide) Visit" indicated there was no documented evidence of a Hospice Aide visiting the patient. During an interview with the Director of Patient Care Services (DPCS) on 10/3/2022 at 12:45 p.m., DPCS stated the office manager informed him Patient 12 declined the Hospice Aide visit but the care plan was not updated. DPCS also stated the care plan needed to be updated as soon as possible to reflect any changes in service provided to patient. A review of the agency's policy, titled ";The Plan of Care," revised in November 2020, indicated ";The care provided to the patient must be in accordance with the plan of care. The plan of care will be reviewed and revised as frequently as deemed necessary, but not less often than every 15 days, by the interdisciplinary group, with input from the attending physician, the patient, and the family/caregiver, based on ongoing comprehensive assessment of the patient and the family/caregiver." b. A review of Patient 14s profile indicates a start of care date to the hospice agency on 4/25/22, with diagnoses including Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 14s record titled, ";Plan of Care", dated 9/29/22 indicated the RN (registered nurse) one visit per week + one visit prn (as needed) visits-initial evaluation then every 14 days thereafter for ongoing comprehensive assessment and supervisory visit." A review of Patient 14s medical record on 9/29/22, at 2:30 p.m., indicated a nursing visit was documented on 9/8/22. No further visits by the RN were documented in Patient 14s medical record. c. A review of Patient 15s profile indicated a start of care date to the hospice agency on 4/26/22 with diagnosis that included heart disease. A review of Patient 15s record titled, ";Plan of Care", dated 9/29/22 indicated, ";RN (registered nurse) one visit per two weeks + one prn (as needed) ..." A review of Patient 15s medical record on 9/29/22, at 2:00 p.m., indicated a nursing visit was documented on 9/13/22. No further visits by the RN were documented in Patient 15s medical record. During an interview on 10/3/22, at 12:20 p.m., the Director of Patient Care Services (DPCS) stated nursing visits are important because the condition of the patient needs to be assessed as well as the needs of the caregiver; also, medications taken at home can be reviewed to make sure they are not expired. The DPCS stated nursing visits were also important to ensure the patient and caregiver are well informed of the care. During an interview on 10/3/22, at 12:40 p.m., the DPCS stated nursing documentation was to be entered right away because the documentation reflects what was done to the patient and what needs to be followed up on. The DPCS stated if there is no documentation of the visits, there is no way to track or follow the progress of the patient. A review of the Hospice Agencys Plan of Correction (a document describing how the agency will correct the deficient practice found during the recertification survey), dated 9/22/22, indicated, ";L 543 A review and audit of patient files was made for corrections and updated to ensure all care and services follow the individualized plan of care regarding frequency of licensed nurse home visits to ensure compliance..."

Based on interview and record review, the Hospice Agency (HA) failed to educate Family Member 1 (FM 1) of one of six sampled patients (Patient 16) regarding the comfort kit (medications used to alleviate symptoms during the end-of-life process) and volunteer services. This deficient practice had the potential to result in Patient 16 not to receive medications and for Patient 16 and his family caregiver/family not to receive services needed to achieve optimal quality of life. --- A review of Patient 16s clinical record indicated Patient 16, a 69-year-old male admitted to the Hospice Agency (HA) on 8/16/2022, with a diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure. A review of Patient 16s ";POC/IDG Review," dated 8/16/2022, 8/31/2022, 9/14/2022, and 9/28/2022, indicated volunteer services were offered but were not needed. There was no documentation if volunteer services were explained to the patient and/or family member/caregiver. During an interview with FM 1 on 9/30/2022 at 11:50 a.m., FM 1 stated the Hospice Agency (HA) did not offer any specific volunteer services. She stated she was not aware of the type of services the hospice volunteer might offer. During an interview with Director of Patient Care Services (DPCS) on 10/3/2022 at 11:55 a.m., DPCS stated the admitting nurse offered volunteer services upon admission. DPCS stated the admitting nurse was responsible to offer and to explain the extent of volunteer services. DPCS stated there was no documented evidence volunteer services were explained to Patient 16 and/or FM 1. DPCS also stated he planned to have the admitting nurse coordinate with the volunteer coordinator (VC). If a patient agreed to receive volunteer services, the VC would arrange the volunteers and visit time. If a patient refused, the VC would call the patient and offer again, and explain the extent of volunteer services. A review of the HAs policy, titled ";Comprehensive Assessment," revised in November 2020, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant and an assessment of the need for volunteer services to offer support or respite to the patient and family/caregiver." b). A review of Patient 16s clinical record indicated Patient 16, a 69-year-old male, was admitted to the Hospice Agency (HA) on 8/16/2022, with a diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure. On 9/30/2022 at 11:30 a.m., during a joint home visit with Director of Patient Care Services (DPCS), medication review was performed and Patient 16 was not provided a comfort kit by the HA, however a review of Patient 16's medication profile listed ";Comfort Kit Comprehensive," which included the following medications: 1). Acetaminophen (pain reliever) 650 milligrams (mg) rectal suppository, one suppository every four hours as needed. 2). Bisacodyl (medication used for constipation) 10 mg rectal suppository, one suppository daily as needed. 3). Levsin (medication used for excessive secretions) 0.125 mg/mL. drops, 1 mL. sublingual every four hours as needed 4). Lorazepam (medication used for anxity) 2 mg/mL. concentrate solution, 0.25 mL. sublingual every four hours as needed. 5). Morphine Sulfate (medication used for moderate to severe pain) 20 mg/mL, 0.25 mL. sublingual every four hours as needed. 6). Prochlorperazine (medication used for nausea) 25 mg rectal suppository, one suppository every 12 hours as needed. On 9/30/2022 at 11:40 a.m., during an interview with Family Member 1 (FM 1), who acted as a caregiver for Patient 16, FM 1 stated there was no comfort kit in the house. She stated she did not know what a comfort kit was, and nobody from the HA had explained or talked to her about a comfort kit. During an interview with DPCS on 9/30/2022 at 11:45 a.m., DPCS stated a comfort kit was important for the patients comfort. He also stated comfort care was the purpose of hospice services. DPCS acknowledged the HA staff should have provided education regarding the comfort kit. A review of the facility's policy titled, "Educational Resources," revised in November 2020 indicated Hospice will provide educational resources that include but will not be limited to written instructions developed by the hospice pertinent to services, pain and symptom management, treatments, medications, etc..."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the comfort kit (medications used to alleviate symptoms during the end-of-life process) was available for two of six sampled patients (Patient 13 and 16). This failure had the potential to affect the quality of life for Patient 13 and 16 by not having a comfort kit available to treat symptoms during the end-of-life process. --- a) A review of Patient 13s profile, indicated a start of care date to the Hospice Agency on 5/18/22, with diagnoses that included atherosclerosis heart disease (buildup of fats, cholesterol, and other substances in and on the artery walls). During an observation of the home visit on 9/30/22, at 1:30 p.m., the Director of Patient Care Services (DPCS) was observed providing care to Patient 13. On 9/30/22, at 1:50 p.m., during an interview, the DPCS stated the following medications listed on the profile were not Patient 13s home: 1). Comfort kit (a group of medications used at the end of life to lessen symptoms). 2). Acetaminophen (pain medicine) 650 mg (unit of measurement) suppository (a specific route for administration). 3). Lorazepam (anxiety medication) 0.25 ml (unit of measurement) sublingual (under the tongue). 4). Morphine Sulfate (pain medicine) 0.25 ml sublingual. 5). Prochlorperazine (to treat nausea) 25 mg one suppository. 6). Levsin (for excessive secretions) one ml sublingual. 7). Bisacodyl (stool softener) 10 mg 1 suppository. On 9/30/22, at 1:50 p.m. during an interview, Patient 13 stated he had never had the comfort kit medications at his home. During a concurrent interview, the DPCS stated it was important to have all medications Patient 13 takes listed on the medication profile to ensure medications are taken safely. The DPCS stated he would follow up with the pharmacy to ensure Patient 13 had his medications at home. b. A review of Patient 16s clinical record indicated Patient 16, a 69-year-old male, was admitted to the Hospice Agency (HA) on 8/16/2022, with a diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure. On 9/30/2022 at 11:30 a.m., during a joint home visit with Director of Patient Care Services (DPCS), a medication review was performed and Patient 16 was not provided a comfort kit by the HA, however a review of Patient 16's medication profile listed ";Comfort Kit Comprehensive," which included the following medications: 1). Acetaminophen 650 mg rectal suppository, 1 suppository every four hours as needed. 2). Bisacodyl 10 mg rectal suppository, one suppository daily as needed. 3). Levsin 0.125 mg/mL. drops, 1 ml sublingual every four hours as needed. 4). Lorazepam 2 mg/mL. concentrate solution, 0.25 ml sublingual every 4 hours as needed 5). Morphine Sulfate 20 mg/mL., 0.25 ml sublingual every four hours as needed. 6). Prochlorperazine 25 mg rectal suppository, one suppository every 12 hours as needed. On 9/30/2022 at 11:40 a.m., during an interview with Family Member 1 (FM 1), who acted as a caregiver for Patient 16, FM 1 stated there was no comfort kit in the house. She stated she did not know what a comfort kit was, and nobody from the HA had explained or talked about a comfort kit. During an interview with DPCS on 9/30/2022 at 11:45 a.m., DPCS stated a comfort kit was important for the patients comfort, thus every patient should be provided with one. He also stated comfort care was the purpose of hospice services. On 10/3/2022 at 11:55 a.m., DPCS stated he had ordered a comfort kit for Patient 16 from the pharmacy after his home visit on 9/30/22. DPCS was not able to provide documentation for the comfort kit order upon request. When asked for the HAs policy for comfort kit, DPCS stated, ";We dont have any policy for comfort kit." A review of the HAs Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by state field staff), completed by the HA on 8/1/2022, indicated the following: ";A review and audit of patient files were made for corrections and updated to ensure compliance. A staff in-service was made with State and Federal Regulations CFR(s): 418.56(c)(5) CONTENT OF PLAN OF CARE. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Educated clinical staff that based on facility's policy titled "Hospice Comfort Kits", "All hospice patients not residing in a nursing home will receive a comfort kit containing emergency medication as ordered by the patient's physician or the Hospice Medical Director ... Comfort Kit medication will be observed directly by the hospice nurse during the first visit of the week to assure that the kit has not expired and is intact and available for use". Also, an in-service was made for clinical staff focused on ensuring the comfort kit was available. Finally, supervisory visits were done by RN to all active patients observing Comfort Kit medication as ordered to assure that the kit has not expired and is intact and available for use by visiting nurse. RN will assess understanding of medications, comfort kit, and use, storage, and safety."

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Based on interview and record review, the hospice agency failed to ensure the Condition of Participations for Clinical Records were met as follows: 1. The hospice agency failed to ensure the contents of the clinical records were protected from any modifications (making partial or minor changes) from unauthorized personnel for 5 of six sampled patients, Patients 4, 13, 14, 15, and 16. This failure had the potential for the clinical records to contain false and inaccurate documentations which can affect the formulation of patients' plan of care and interventions and can affect the quality of care and services provided by the agency to all the patients under their care. (Refer to L 679) 2. The hospice agency failed to ensure, for two of six sampled patients, (Patient 14 and Patient 15), the clinical records were not intentionally accessed to enter clinical notes by staffs not directly involved in providing patient care and services. Visit notes were entered under a Registered Nurse (RN) name who was off work. This deficient practice violated the patients rights to privacy and confidentiality and had the potential that false and incorrect information were entered in the clinical records that can potentially affect the care planning process and interventions formulated for the care of the affected patients and can affect the quality of care and services provided to the affected patients. (Refer to L680) The cumulative effect of these systemic problems resulted in the hospice agencys inability to ensure provision of a quality health care in a safe environment. --- .

Based on interview and record review, the hospice agency failed to ensure the contents of the clinical records were protected from any modifications (making partial or minor changes) from unauthorized personnel for 5 of six sampled patients, Patients 4, 13, 14, 15, and 16. This failure had the potential for the clinical records to contain false and inaccurate documentations which can affect the formulation of patients' plan of care and interventions and can affect the quality of care and services provided by the agency to all the patients under their care. --- c). A review of Patient 13s profile, indicated a start of care date to the Hospice Agency on 5/18/22, with diagnoses that included atherosclerosis heart disease (buildup of fats, cholesterol, and other substances in and on the artery walls). During a review of Patient 13s electronic medical record on 9/29/22, at 1:30 p.m., the Interdisciplinary Group (IDG) review of Patient 13s plan of care was documented for 8/3/22 and 8/17/22. No further IDGs were documented. d). A review of Patient 14s profile indicates a start of care date to the Hospice Agency on 4/25/22, with diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a review of Patient 14s electronic medical record on 9/29/22, at 2:30 p.m., the Interdisciplinary Group (IDG) review of Patient 14s plan of care was documented for 8/3/22, 8/17/22, and 8/31/22. No further IDGs were documented. e). A review of Patient 15s profile indicated a start of care date to the Hospice Agency on 4/26/22 with diagnoses that included heart disease. During a review of Patient 15s electronic medical record on 9/29/22, at 2:00 p.m., the Interdisciplinary Group (IDG) review of Patient 15s plan of care was documented for 8/3/22, 8/17/22, and 8/31/22. No further IDGs were documented. During an interview on 10/3/22, at 12:40 p.m., the DPCS stated it was important to document the findings in the IDG meetings in the patients record to know what the needs of the patient were and what information the group needs to know to follow up on. When the DPCS was asked how you know what to follow up on if the IDGs are not documented? The DPCS stated ";You are right because the IDG meetings are not documented." A concurrent interview and record review on 10/3/22, at 12:50 p.m., of Patient 13s record titled ";Audit log", dated 9/29/22 to 10/3/22, was reviewed with the Director of Patient Care Services (DPCS). The DPCS stated the IDG notes following the last documented IDG notes of 8/17/22, were entered on 9/30/22. During a concurrent interview and record review on 10/3/22, at 12:50 p.m., of Patient 14s record titled ";Audit log", dated 9/29/22 to 10/3/22, was reviewed with the Director of Patient Care Services (DPCS). The DPCS stated the IDG notes following the last documented IDG notes of 8/31/22, were entered on 9/30/22. During a concurrent interview and record review on 10/3/22, at 12:50 p.m., of Patient 15s record titled ";Audit log", dated 9/29/22 to 10/3/22, was reviewed with the Director of Patient Care Services (DPCS). The DPCS stated the IDG notes following the last documented IDG notes of 8/31/22, were entered on 9/30/22. A review of the Hospice Agencys Plan of Correction (a document describing how the agency will correct the deficient practice found during the recertification survey), dated 9/22/22, indicated, ";L 679...A staff in-service was made with State and Federal Regulations...All entries must be legible, clear complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice...The hospice agency will take appropriate steps to protect the integrity of ePHI that it creates, receives, maintains, or transmits from unauthorized modification. Also, an in-service provided to clinical staff focused on ensuring that all clinical records were not modified..." a). A review of Patient 4s clinical record indicated Patient 4 was a 77-year-old female admitted to the Hospice Agency (HA) on 6/1/2022, with a diagnosis of heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), unspecified. The electronic medical record for Patient 4, titled "Audit Log" (a document that records an event in an information technology/IT system; it documents what resources were accessed, and entries usually include patients name, modification date, a timestamp and user login information), dated 9/29/2022 to 10/3/2022, indicated that on 9/29/2022 at 11:49 a.m. to 10/3/2022 at 11:36 a.m., the clinical records were modified. b). A review of Patient 16s clinical record indicated Patient 16 was a 69-year-old male admitted to the Hospice Agency (HA) on 8/16/2022, with a diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure. The electronic medical record for Patient 16, titled "Audit Log" (a document that records an event in an information technology/IT system; it documents what resources were accessed, and entries usually include patients name, modification date, a timestamp and user login information), dated 9/29/2022 to 10/3/2022, indicated that on 9/29/2022 at 11:47 a.m. to 10/3/2022 at 11:58 a.m., the clinical records were modified. During an interview with Director of Patient Care Services (DPCS) on 10/3/2022 at 12:50 p.m., the DPCS stated the IDG notes were entered as shown in the audit trail, which was between 9/29/2022 and 10/3/2022. A review of the Hospice Agencys Plan of Correction (a document submitted by licensed health care facilities to respond to deficiencies identified in a survey of the facility conducted by state field staff), dated 9/22/2022, indicated, ";L 679...A staff in-service was made with State and Federal Regulations...All entries must be legible, clear complete, and appropriately authenticated and dated in accordance with hospice policy and currently accepted standards of practice...The hospice agency will take appropriate steps to protect the integrity of ePHI that it creates, receives, maintains, or transmits from unauthorized modification. Also, an in-service provided to clinical staff focused on ensuring that all clinical records were not modified..."

Based on interview and record review, the hospice agency failed to ensure, for two of six sampled patients, (Patient 14 and Patient 15), the clinical records were not intentionally accessed to enter clinical notes by staffs not directly involved in providing patient care and services. Visit notes were entered under a Registered Nurse (RN) name who was off work. This deficient practice violated the patients rights to privacy and confidentiality and had the potential that false and incorrect information were entered in the clinical records that can potentially affect the care planning process and interventions formulated for the care of the affected patients and can affect the quality of care and services provided to the affected patients. --- a). A review of Patient 14s profile indicated a start of care date to the Hospice Agency on 4/25/22, with diagnoses that included Alzheimers disease (a progressive disease that destroys memory and other important mental functions). Further review of the record indicated Patient 14 lived in Sacramento, California. A review of Patient 14s record titled, ";Plan of Care" (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers), dated 9/29/22 indicated, ";RN (registered nurse) visit one per week and one visit prn (as needed) visits-initial evaluation then every 14 days thereafter for ongoing comprehensive assessment and supervisory visit." A review of Patient 14s medical record on 9/29/22, at 2:30 p.m., indicated a nursing visit documented on 9/8/22 and had no further visits documented after that. On 9/30/22, the agency provided the survey team two documents for Patient 14, titled, ";Visit Note RN" for visit dates 9/13/22 and 9/29/22 that were both written by Registered Nurse 1 (RN1). A review of Patient 14s record titled, ";Audit Log" (a record of all creations, modifications, additions, deletions, etc. made to the patient care record), dated 9/29/22 to 10/3/22, indicated the Visit Note RN for visit dates 9/13/22 and 9/29/22 were created on 9/30/22 by RN 1. b). A review of Patient 15s profile indicated a start of care date to the Hospice Agency on 4/26/22 with diagnoses that included heart disease. Further review of the record indicated Patient 15 lived in Sacramento, California. A review of Patient 15s record titled, ";Plan of Care", dated 9/29/22 indicated, ";RN (registered nurse) one visit per two weeks and one visit prn (as needed)." A review of Patient 15s medical record on 9/29/22, at 2:00 p.m., indicated a nursing visit documented on 9/13/22 and had no further visits documented after that. On 9/30/22 the agency provided to the survey team two documents for Patient 15, titled ";Visit Note RN" for visit dates 9/13/22 and 9/29/22 by RN 1. A review of Patient 15s record titled, ";Audit Log" dated 9/29/22 to 10/3/22, indicated the Visit Note RN for visit dates 9/13/22 and 9/29/22 were created on 9/30/22 by RN 1. During an interview on 10/3/22, at 11:20 a.m., RN 1 stated she lives in Glendale, CA and was not familiar with Patients 14 and 15, and stated, she had not visited the patients, nor talked to them on the phone, or had a nursing visit through facetime (video-telephone call). When RN 1 was informed that there were visit notes for Patients 14 and 15 on 9/30/22 that were created under her name, RN1 stated she didnt know why the notes were there. RN 1 stated she was working at her other job on 9/29/22 and was not with Patients 14 and 15 to take vital signs nor did examine the patients. RN 1 further stated she have not shared her username and password and does not know who else might have her username or password. During an interview on 10/3/22, at 11:35 a.m., the Director of Patient Care Services (DPCS) stated he did not have an explanation on why there were notes under RN 1s name, if RN 1 says she didnt know the patient, or she has not seen the patient. A review of the Hospice Agencys Plan of Correction (a document describing how the agency will correct the deficient practice found during the recertification survey), dated 9/22/22, ";L 680...The clinical records, its contents and the information contained therein must be safeguarded against loss or unauthorized use...access to patient information files will be limited to organization personnel involved in the care of the patient..."

Based on interview and record review, the Hospice Agency failed to notify the local licensing department regarding change of administrator and director of patient care services within 10 days of the change. This deficient practice resulted in the agencys inability to follow local state laws. --- On 10/3/22, at 11:55 a.m., the Director of Patient Care Services (DPCS) stated he was the administrator and DPCS since 9/1/22. The DPCS stated he needed to notify the local licensing department regarding the change of administrator and DPCS within 30 days. The DPCS stated he sent the letter to the local licensing department on 9/29/22. A review of the agencys record titled ";Comprehensive Hospice Services LCC", dated 9/1/22, indicated, ";The Governing Body approved the appointment of ...as the Administrator, DPCS, and QAPI LEAD." A review of the agencys record titled ";Macgroup", dated 9/29/22, indicated, ";We are submitting a change of administrator and change of DPCS application for the hospice agency known as Comprehensive Hospice Services, LLC..."

It is required that the documented comprehensive assessment includes a drug profile that contains the patient's current prescription and over-the-counter (OTC) drugs, supplements, herbal remedies, other alternative treatments that could affect drug therapy. The drug profile is updated per the hospice policy and procedure, but, at minimum, at the time of each comprehensive assessment and/or when new medication is added or changes are made to existing medication. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 2 of 11 (18%) records reviewed revealed the medication profile lacked medications the patient was prescribed and/or currently taking. Record #9 was reviewed and identified the patient elected hospice care on 12/21/2021. The medication profile dated 12/21/2021 was reviewed and revealed the profile did not list any medications. During an interview with the Director of Patient Care Services/Administrator (DCPS), it was reported the patient was taking herbal supplements. The DPCS stated that herbal supplements are counted and should have been included on the medication profile. Record #8 was reviewed and identified the patient elected hospice care on 2/3/2022. For the certification period 2/3/22 - 5/3/22, the Certificate of Terminal Illness (CTI) dated 2/3/2022, documented the patient's use of "oxygen 2 liters/minute via nasal cannula." The medication profile dated 2/3/2022 was missing oxygen. The agency's policy #2-004 "Medication Profile" (Revised 11/2020), stated in part, " Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record."

It is required that the comprehensive assessment includes an initial bereavement assessment of the needs of the patient's family and other individuals, focusing on the social, spiritual, and cultural factors that may impact their ability to cope with the patient's death. Information gathered from the initial bereavement assessment is incorporated into the plan of care and considered in the bereavement plan of care. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. In 4 of 11 (36%) records reviewed revealed no documented evidence of a completed initial bereavement assessment. Record #5 was reviewed and identified the patient elected hospice care on 9/8/2022. The record was missing evidence of a documented initial bereavement assessment. Record #2 was reviewed and identified the patient elected hospice care on 2/2/2022. The record was missing evidence of a documented initial bereavement assessment. Record #7 was reviewed and identified the patient elected hospice care on 8/4/2022. The record was missing evidence of a documented initial bereavement assessment. Record #10 was reviewed and identified the patient elected hospice care on 6/1/2022. The record was missing evidence of a documented initial bereavement assessment. The agency's policy #1-021 "Bereavement Assessment" (Revised 11/2020), stated in part, "On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment . . ." During an interview on 8/16/2022, the Director of Patient Care Services (DPCS)/Administrator (Admin) reviewed and agreed with the above findings, stating the lack of understanding of the electronic medical record capability was at issue. Per the DPCS/Admin, prior to the end of the site visit, the agency had reviewed the electronic medical record capability with all staff, and the active patients will have an initial bereavement assessment completed.

It is required that each patient’s individualized written plan of care reflects patient and family goals and identifies planned interventions based on problems identified in the initial and updated comprehensive assessments. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 2 of 11 (18%) records reviewed revealed the hospice failed to ensure that the plan of care reflected patient and family goals and interventions based on problems identified in the initial and updated comprehensive assessments. Record #9 was reviewed and identified the patient elected hospice care on 12/21/2021. For the certification period dated 12/21/2021 to 3/20/2022, the Certificate of Terminal Illness (CTI) dated 12/21/21 stated the patient had bowel and bladder incontinence. The plan of care (POC) dated 12/21/21 lacked a goal and intervention(s) for bowel and bladder incontinence. Record #8 was reviewed and identified the patient elected hospice care on 2/3/22. For the certification period dated 2/3/2022 to 5/3/2022, the CTI dated 2/3/22 documented the patient was using "oxygen 2 liters/minute via nasal cannula." The plan of care dated 2/3/22 lacked a goal and intervention(s) for oxygen. The agency policy #9-017 "The Plan of Care" (Revised 11/2020), stated in part, "The plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group. This plan will focus on identified problems, goals, and interventions." DPCS/Administrator Interview During an interview on 8/17/22, the Director of Patient Care Services/Administrator reviewed and agreed with the findings above.

It is required that the Interdisciplinary Group, in collaboration with the individual's attending physician (if any), reviews, revises, and documents the individualized care plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 3 of 9 (33%) records reviewed of patients with a start of care date prior to 7/31/2022 revealed the agency failed to ensure that the interdisciplinary group (IDG) reviewed, revised, and documented the individualized plan as frequently as the patient's condition requires, but no less frequently than every 15 calendar days. Record #10 was reviewed and identified the patient elected hospice care on 6/1/2022. A review of the record revealed an IDG and plan of care (POC) in the clinical record dated 8/3/2022. The record was missing evidence of the IDG and POC update for 7/20/2022. Record #5 was reviewed and identified the patient elected hospice care on 9/8/2021. A review of the record revealed an IDG and plan of care (POC) in the clinical record dated 7/6/2022. The record was missing evidence of the IDG and POC updates for 7/20/2022 and 8/3/2022. Record #0 was reviewed and identified the patient elected hospice care on 4/29/22. A review of the record revealed an IDG and plan of care (POC) in the clinical record dated 7/6/2022. The record was missing evidence of the IDG and POC updates for 7/20/22 and 8/3/22. The agency's policy #1-036 "Interdisciplinary Group Meeting" (Revised 11/2020), stated in part, "Each patient's plan of care will be updated utilizing the results from ongoing comprehensive assessment no less frequently than every 15 days . . ." During an interview on 8/17/22, the Director of Patient Care Services/Administrator reviewed and agreed with the above findings.

It is required that counseling services include an organized program for providing bereavement services delivered by or under the supervision of a qualified professional with experience or education in grief or loss counseling. Bereavement services are available to the family and other individuals up to one (1) year following the death of the patient. Bereavement counseling extends to residents of a SNF/NF (skilled nursing facility/nursing facility) or ICF/IDF (intermediate care facility/intellectual disability facility) when appropriate and identified in the bereavement plan of care. The bereavement services reflect the needs of the bereaved per a bereavement plan of care that includes the types of bereavement services to be offered and the frequency of service delivery. This standard was not met as evidenced by a review of clinical records, document reviews, and interviews. 1 of 1 (100%) applicable records reviewed of deceased patients revealed the hospice did not ensure that a bereavement plan of care was documented. Record #9 was reviewed and identified the patient elected hospice care on 12/21/2021. The patient died on 1/5/2022. The post-death bereavement assessment was completed on 1/9/2022 with a finding of low-risk. The record included evidence that bereavement services and interventions were provided to the family, but the record was missing a documented bereavement plan of care. The agency's policy #1-021 "Bereavement Assessment" (Revised 11/2020), stated in part, "The Bereavement Coordinator will develop a plan for intervention based on the findings of the bereavement follow-up assessment." During an interview on 8/17/2022, the Director of Patient Care Services (DPCS)/Administrator reviewed and agreed with the finding above. The DPCS explained understanding functionality of the electronic medical record contributed to this issue. Per the DPCS, prior to the end of site visit, the bereavement coordinator had added a bereavement plan of care, and already has a better understanding how to document the post-death bereavement.

It is required that a hospice aide provides services ordered by the Interdisciplinary Group and included in the plan of care. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 2 of 3 (66%) records reviewed of patients receiving hospice aide services revealed the hospice did not ensure the hospice aide followed the visit frequency ordered and included in the plan of care. Record #0 was reviewed and identified the patient elected hospice care on 4/29/2022. The first aide plan of care dated 6/1/2022 documented the hospice aide visit frequency as, "1x/week." The record was missing evidence of completed hospice aide visits, as of 8/17/2022. In addition, the record did not include documentation as to why the visits were missed, or communication with the physician to update the plan of care. Record #6 was reviewed and identified the patient elected hospice care on 8/1/2022. The aide plan of care dated 8/1/2022 documented the hospice aide visit frequency as, "1x/week." The record was missing evidence of completed hospice aide visits for the weeks of 8/1/2022 and 8/8/2022. In addition, the record did not include documentation as to why the visits were missed, or communication with the physician to update the plan of care. The agency's policy #9-020 "Hospice Aide Services" (Revised 11/2020), stated in part, "Hospice aide services will include personal care services provided by trained hospice aides. . . These activities are in accordance with the plan of care and physician's orders will be assigned and supervised by a hospice registered nurse." During an interview on 8/17/2022, the Director of Patient Care Services/Administrator reviewed and agreed with the finding above. It was reported the plan of correction process was started prior to the end of the site visit to address the findings.

It is required that a patient clinical record containing past and current findings is maintained for each hospice patient. The record contains correct clinical information that is available to the patient’s attending physician and hospice staff that includes signed copies of the notice of patient rights and the hospice election statement. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 3 of 11 (27%) records reviewed revealed the hospice agency did not ensure the record contains signed copies of the hospice election statement per the agency's policy. Record #2 was reviewed and identified the patient elected hospice care on 2/2/22. The record contained initials of the patient/representative which indicated that the election statement addendum had been requested at the time of the initial hospice election. The record lacked evidence that the addendum was completed and provided to the patient/representative within 5 days from the date of election. Record #8 was reviewed and identified the patient elected hospice care on 2/3/22. The record contained initials of the patient/representative which indicated that the election statement addendum had been requested at the time of the initial hospice election. The record lacked evidence that the addendum was completed and provided to the patient/representative within 5 days from the date of election. Record #9 was reviewed and identified the patient accepted hospice care on 12/21/21. The record contained initials of the patient/representative which indicated that the election statement addendum had been requested at the time of the initial hospice election. The record lacked evidence that the addendum was completed and provided to the patient/representative within 5 days from the date of election. The agency's policy #1-031 "Hospice Election Statement" (Revised 11/2020), stated in part, "If the election statement addendum is requested at the time of the initial hospice election, the organization must provide the addendum, in writing, to the patient/representative within five (5) days from the date of election." During an interview on 8/17/22, the Director of Patient Care Services/Administrator reviewed and agreed that the addendum was requested and had not been provided within 5 days of each patient/representative requests.

It is required that if a patient revokes the election of hospice care or is discharged from hospice per hospice regulation §418.26 (i.e., no longer terminally ill), the hospice forwards to the patient’s attending physician a copy of the hospice discharge summary, and the patient's record, if requested. This standard was not met as evidenced by a review of clinical records, document reviews and interviews. 2 of 2 (100%) records reviewed of patients discharged from hospice services revealed the agency failed to forward to the patient's attending physician a copy of the hospice discharge summary. Record #8 was reviewed and identified the patient elected hospice care on 2/3/2022. The patient and family revoked hospice services on 5/3/2022. The record was missing evidence that a discharge summary was forwarded to the patient's attending physician. Record #2 was reviewed and identified the patient elected hospice care on 2/2/2022. The patient and family revoked hospice services on 5/2/2022. The record was missing evidence that a discharge summary was forwarded to the patient's attending physician. The agency's policy #1-024 "Revocation of Hospice Benefit (Revised11/2020)," stated in part, "The Case Manager will notify the attending physician and interdisciplinary group about the revocation and reason. A discharge summary will be sent to the attending physician." During an interview on 8/17/22, the Director of Patient Care Services/Administrator reviewed and agreed with the above findings.

It is required that hospice staff, in coordination with SNF/NF or ICF/IDF staff, ensures orientation and training of staff providing care to hospice patients. At a minimum, the orientation and training includes introduction to hospice philosophy, hospice policies and procedures regarding methods of comfort, pain control, and symptom management, principles about death and dying, and individual responses to death, patient rights, and appropriate forms and record keeping requirements. This standard was not met as evidenced by a review of documents and interviews. The agency failed to ensure that hospice staff, in coordination with the skilled nursing facility (SNF) staff, provides orientation and training to SNF staff caring for hospice patients per the agency's policy. A review of the agency's administrative and educational documents revealed no evidence of training materials available to provide education to the SNF staff. There was no evidence that the agency had consulted with the SNF regarding the training needs of the SNF staff. During an interview on 8/16/2022, with the Director of Patient Care Services (DPCS)/Administrator (Admin), it was reported that the agency had not provided orientation and training of staff at the contracted SNF. The DPCS/Admin reported no agency patients have been cared for at the contracted SNF. Prior to the end of the site visit, the agency started developing an education PowerPoint that includes required key education points to use for the SNF training. The agency's policy #1-030 “Provision of Care to Residents of SNF/NF or ICF/IID" (Revised 11/2020), stated in part, "Agency will consult with SNF/NF or ICF/IID regarding the shared orientation and training responsibilities of staff furnishing care to patients, including... Hospice philosophy... Hospice policies and procedures regarding methods of comfort, pain control, symptom management, and postmortem care... Principles about death and dying and individual responses to death... Patient rights... Appropriate forms and record keeping requirements." The agency has not provided the required orientation and training to the Skilled Nursing Facility staff that will be providing care for the agency hospice patients as per the agency's Provision of Care to Residents of SNF/NF or ICF/IID Policy.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Initial and Comprehensive Assessment of Patients was met as follows: 1. Failed to review the medication profile and the current home medications for one of 11 sampled patients, Patient 6. (Refer to L530) 2. Failed to ensure a bereavement assessment (assessing participants and grieving families to ensure that appropriate bereavement services are provided through the continuum of care from enrollment through the year following the death of the participant) was conducted to provide bereavement counseling in accordance to the patient and family's needs for five of 11 sampled patients, Patients 6, 7, 8, 10, and 11. (Refer to L531) 3. Failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) met and updated the comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) at least every 15 days for six of 11 sampled patients, Patients 6,7,8,9,10, and 11. (Refer to L533) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated federal compliance to ensure the highest quality of care and services are provided to the patients under their care.

Based on observation, interview and record review, the hospice agency failed to review the medication profile and the current home medications for one of 11 sampled patients, Patient 6. This failure had the potential for medication errors and adverse drug reactions which can affect the health and safety of Patient 6. Findings: On 7/15/2022 at 9:05 a.m., a home visit was conducted with the Licensed Vocational Nurse (LVN). Patient 6 was observed lying in bed. On 7/15/2022, at 9:31 a.m., during an observation, the Licensed Vocational Nurse (LVN) did not review the medication Patient 6 was taking. During the review of Patient 6's medication profile, Flomax (medication used to treat symptoms of enlarged prostate) 0.4 milligrams (mg) 1 capsule by mouth every day was not included in the lists of medications Patient 6 was taking. A review of Patient 6's admission record indicated Patient 1 was admitted to the hospice agency on 5/20/2022, with diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. A review of Patient 6's undated medical record titled "Current Treatments/Medication/DME List" indicated the following medication were listed but not observed in the patient's home: 1. Acetaminophen (medicine for pain) 650 milligrams (mg), 1 suppository per rectum every four (4) hours as needed for mild pain or fever. 2. Bisacodyl (medicine that helps empty bowels) 10 mg. rectal suppository, 1 suppository per rectum daily as needed for constipation (difficulty in emptying the bowels). 3. Levsin 0.125 mg 1 milliliter (ml), sublingual (under the tongue) every 4 hours as needed for excessive secretions. 4. Lorazepam 2 mg/ml, 0.25 ml sublingual every 4 hours as needed for anxiety or agitation. 5. Morphine sulfate 20 mg/ml 0.25 ml sublingual every two (2) hours as needed for severe pain or shortness of breath. 6. Prochlorperazine 25 mg 1 suppository per rectum every 12 hours as needed for nausea or vomiting. 7. Metoprolol 25 mg.1 tab daily for hypertension. During further review of the clinical record, the following lists of medications were observed listed twice: 1. Losartan Potassium (medicine used for hypertension) 100 mg. tablet. 2. Tamsulosin Hydrochloride (medication used to treat enlarged prostate) 0.4 mg. capsule. 3. Amlodopine Besylate (medicine for hypertesnion) 2.5 mg tablet. 4. Atrovastatin Calcium (medicine to lwer cholesterol level) 20 mg. tablet. During an interview on 7/19/2022, at 12:40 p.m., the Director of Patient Care Services (DPCS) stated the nurse was supposed to check the medication every visit. They should check the bottle for expiration date, dose, frequency, purpose, route and everything. We have to compare the medication to the medication profile which is in paper form. If there are changes, we update the medication profile, such as discontinued meds, must be documented when discontinued. If there are new medications and other changes, we must update everything like the dosage, frequency, and update the medication profile. Sometimes, we know it after the interdisciplinary team meeting (IDT, members of the treatment team coordinating care and to document the communication among all members of the team related to the patient's plan of care and treatment goals) report by the nurse." A review of facility's policy titled, "Medication Profile", revised November 2020, indicated, "The medication profiles will be updated for each change to reflect current medications. For new and/or discontinued medications ..."

Based on interview and record review, the hospice agency failed to ensure a bereavement assessment (assessing participants and grieving families to ensure that appropriate bereavement services are provided through the continuum of care from enrollment through the year following the death of the participant) was conducted to provide bereavement counseling in accordance to the patient and family's needs for five of 11 sampled patients, Patients 6, 7, 8, 10 and 11. This failure had the potential of not providing the social, spiritual and cultural supports the patient and family needed in relation to the patient's anticipated death and can affect the psychosocial well being of the affected patients and families. Findings: During an interview and concurrent review on 7/19/2022, at 1:10 p.m. for Patient 6's electronic medical record, the Director of Patient Care Services (DPCS), stated there was no evidence the bereavement assessment was done for Patient 6, it was supposed to be done within 5 days. During a review of Patient 6's admission record, indicated Patient 6 was admitted to the hospice agency (HA) on 5/20/2022, with a diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. Patient 6's clinical record did not indicate a documented evidence bereavement assessment was conducted. During a review of Patient 7's admission record, indicated Patient 7 was admitted to the HA on 6/18/2022, with diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. The clinical record did not indicate documented evidence a bereavement assessment was conducted. A review of Patient 8's admission record, indicated Patient 8 was admitted to the HA on 6/18/2022 with a diagnosis of heart failure (heart muscle does not pump blood as well as it should). The clinical record did not indicate documented evidence a bereavement assessment was conducted. A review of Patient 10's admission record, indicated Patient 10 was admitted to the HA on 10/4/2021 with a diagnosis of malignant neoplasm of uterus (uterine cancer). The clinical record did not indicate documented evidence a bereavement assessment was conducted. A review of Patient 11's admission record, indicated Patient 11 was admitted to the HA on 7/20/2021 with a diagnosis of acute kidney failure. The clinical record did not indicate documented evidence a bereavement assessment was conducted. During an interview on 7/19/2022, at 12:25 p.m., the DPCS stated, "The pastoral care is responsible for the initial bereavement assessment, because that is his main role in this agency. It is supposed to be done within 5 days of the start of care because you don't know the condition of the patient and they can pass at any time." A review of facility's policy titled, "Bereavement Assessment", revised November 2020 indicated, "The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of the patient's death as part of the comprehensive assessment. It also indicated that on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator".

Based on observation, interview and record review, the agency failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) met and updated the comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) at least every 15 days for six of 11 sampled patients, (Patients 6,7,8,9,10, and 11). This deficient practice had potential that the needs and concerns of the affected patients are not addressed, goals are not achieved, which can affect the highest practicable mental, physical and psychosocial well-being of the patients under the agency's care. Findings: During a review of the clinical record on 7/19/2022 at 12:00 p.m., Patient 6's admission record indicated Patient 6 was admitted on 5/20/2022, with diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. The clinical record for Patient 6 titled, "POC/IDG (Plan of Care/ Interdisciplinary Group) Review" did not indicate signatures that the Medical Social worker (MSW) and Spiritual Counsellor (SC) had attended the reviews on 5/20/22, 5/25/22, 6/8/22, 6/22/22 and 7/6/22. A review of Patient 7's admission record, indicated the patient was admitted to the HA on 6/18/22, with a diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. The "POC/IDG Review" for Patient 7 did not indicate signatures that the MSW and SC had attended the reviews on 6/18/22, 6/22/22 and 7/6/22. A review of Patient 8's admission record indicated the patient was admitted to the HA on 6/18/22 with a diagnosis of heart failure (heart muscle does not pump blood as well as it should). The "POC/IDG Review" for Patient 8 did not indicate signatures that the MSW and SC had attended the reviews on 6/18/22. Also, on 6/22/22, the "POC/IDG Review" did not indicate signatures that the MSW, SC and the doctor had attended the reviews, and on 7/6/22, the "POC/IDG Review" did not indicate signatures that the doctor, registered nurse, MSW and SC had attended the review. A review of Patient 9's admission record indicated Patient 9 was admitted on 9/8/21 with diagnosis of heart disease. The "POC/IDG Review" for Patient 9 did not indicate signatures that the MSW and SC had attended the reviews on 5/25/22, 6/8/22, 6/22/22 and 7/6/22. A review of Patient 10's admission record indicated Patient 10 was admitted on 10/4/21 with a diagnosis of malignant neoplasm of uterus (uterine cancer). A review of Patient 10's medical record titled "POC/IDG Review", did not indicate signatures that the MSW and SC had attended the reviews on 10/4/21, 10/13/21, 10/27/21 and 7/6/22. A review of Patient 11's admission record indicated Patient 11 was admitted on 7/20/21 with a diagnosis of acute kidney failure. The clinical records and electronic medical record did not indicate any IDG team meeting were held to discuss the plan of care for Patient 11. During an interview on 7/19/2022, at 12:15 p.m., the Director of Patient Care Services (DPCS) stated the doctor, registered nurse, medical social worker, and spiritual counselor were members of the interdisciplinary group (IDG). The DPCS stated the IDG members meet every two weeks to discuss the patient's immediate needs and update the plan of care especially if there are changes. The DPCS also stated the signatures on the record indicated the members attended the meeting. A review of facility's policy titled, "Interdisciplinary Group (IDG) Meeting" revised November 2020, indicated, "The IDG will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care . Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. It also indicated, the hospice Medical Director and all hospice IDG members will be present. The members at the IDG meeting will sign an attendance form."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation regarding Idg, Care Planning and Coordination of Services for patients was met as follows: 1. The HA failed to designate an interdisciplinary group (IDG), in consultation with the patient's physician, in preparing the written plan of care (POC) for five of 11 sampled patients (Patients 6,7,8,10, and 11). There was no evidence the Medical Social Worker (MSW), and Chaplain had participated in preparing the the POC. (Refer to L537) 2. The HA failed to designate an interdisciplinary group (IDG), in consultation with the patient's physician, in preparing the written plan of care (POC) for five of 11 sampled patients (Patients 6,7,8,10, and 11). There was no evidence the MSW (medical social worker) and Chaplain had participated in preparing the written POC. (Refer to L541) 3. The Hospice Agency (HA) failed to ensure all care and services follow the individualized plan of care regarding frequency of licensed nurse home visits for three of 11 sampled patients (Patient 6, 7, and 8). (Refer to L543) 4. The HA failed to educate one of 11 sampled patients (Patient 1) Care Giver (CG1) on how to properly perform wound care services. (Refer to L544) 5. The HA failed to ensure the comfort kit (medications used to alleviate symptoms during the end-of-life process) was available for one of 11 sampled patients (Patient 6). (Refer to L 550) 6. The HA failed to ensure all care services furnished followed individualized plans of care established be the interdisciplinary team (IDT) by not conducting home visits as indicated in the plan of care for three of 11 sampled patients (Patients 1, 4, and 5). (Refer to L555) 7. The HA failed to ensure the care giver (CG 1) of two out of 11 sampled patients (Patients 1 and 2) was provided with the patient's plan of care (POC) information regarding the services/care being provided by the HA. (Refer to L558) These deficient practices resulted in the HA not providing the services/care as ordered and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life.

Based on interview and record review, the Hospice Agency (HA) failed to designate an interdisciplinary group (IDG), in consultation with the patient's physician, in preparing the written plan of care (POC) for five of 11 sampled patients (Patients 6,7,8,10, and 11). There was no evidence the Medical Social Worker (MSW), and Chaplain had participated in preparing the POC. This deficient practice could potentially prevent the patients from reaching their care planning goals. Findings: A review of Patient 6's admission record indicated the patient was admitted to the HA on 5/20/22, with a diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. During an interview on 7/19/22, at 12:15 p.m., the Director of Patient Care Services (DPCS) stated the nurse and the doctor create the plan of care once the initial nursing assessment is done. The DPCS stated the participants of the interdisciplinary group (IDG) were the doctor, registered nurse, medical social worker (MSW), and the spiritual counselor (SC). A review of Patient 6's medical record titled, "POC/IDG review", dated 5/20/22, indicated "IDG discussion/update comprehensive assessment review: SC was informed of new admission. SC will call the patient/family for initial evaluation within 5 days of SOC to identify emotional and spiritual support to patient and family. LCSW was informed of new admission. LCSW will call the patient/family for initial evaluation within 5 days of SOC to identify emotional and psychosocial support to patient and family." Further review of the record did not indicate the MSW and SC contributed to the development of the POC. A review of Patient 7's admission record indicated the patient was admitted to the HA on 6/18/22, with a diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. A review of Patient 7's medical record titled, "POC/IDG review", dated 6/18/22, indicated "IDG discussion/update comprehensive assessment review: SC was informed of new admission. SC will call the patient/family for initial evaluation within 5 days of SOC to identify emotional and spiritual support to patient and family. LCSW was informed of new admission. LCSW will call the patient/family for initial evaluation within 5 days of SOC to identify emotional and psychosocial support to patient and family." Further review of the record did not indicate the MSW and SC contributed to the development of the POC. A review of Patient 8's admission record indicated the patient was admitted to the HA on 6/18/22 with a diagnosis of heart failure (heart muscle does not pump blood as well as it should). A review of Patient 8's medical record titled "POC/IDG review", dated 6/18/22, indicated "IDG discussion/update comprehensive assessment review: SC will call the patient/family for initial evaluation within 5 days of SOC to identify spiritual needs to patient/family. LCSW will call the patient/family for initial evaluation within 5 days of SOC to identify psychosocial and emotional concerns to patient/family." Further review of the record did not indicate the MSW and SC contributed to the development of the POC. A review of Patient 10's admission record indicated the patient was admitted to the HA on 10/4/21 with a diagnosis of malignant neoplasm of uterus (uterine cancer). A review of Patient 10's medical record titled, "POC/IDG review", dated 10/4/21, indicated "IDG discussion/update comprehensive assessment review: Chaplain visits-initial assessment within 5 days to provide spiritual support to patient and family. MSW visits-initial assessment within 5 days to provide psychosocial support to patient and family." Further review of the record did not indicate the MSW and SC contributed to the development of the POC. A review of Patient 11's admission record indicated the patient was admitted to the HA on 7/20/21 with a diagnosis of acute kidney failure. A review of Patient 11's medical records and electronic medical record did not indicate any records the IDG team met to discuss and develop the plan of care for Patient 11. A review of facility's policy titled, "Interdisciplinary Group (IDG) Membership and Responsibilities" revised November 2020 indicted, "The hospice IDG membership includes at a minimum: Physician, Registered Nurse, Social Worker, and Pastoral or other counselor ... The IDG responsibilities include but are not limited to: A. Consulting with the patient's attending physician (if any), completes the initial comprehensive assessment within five (5) calendar days after the election of hospice care. B. Participation in the establishment of the plan of care for each patient admitted to the hospice services

Based on interview and record review, the Hospice Agency (HA) failed to designate an interdisciplinary group (IDG), in consultation with the patient's physician, in preparing the written plan of care (POC) for five of 11 sampled patients (Patients 6,7,8,10, and 11). There was no evidence the MSW (medical social worker) and Chaplain had participated in preparing the written POC. This deficient practice could potentially prevent the patients from reaching their care planning goals. Findings: A review of Patient 6's admission record indicated the patient was admitted to the HA on 5/20/22, with a diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. A review of Patient 6's medical record titled, "POC/IDG review", dated 5/20/22, indicated "IDG discussion/update comprehensive assessment review: SC was informed of new admission. SC will call the patient/family for initial evaluation within 5 days of SOC to identify emotional and spiritual support to patient and family. LCSW was informed of new admission. LCSW will call the patient/family for initial evaluation within 5 days of SOC to identify emotional and psychosocial support to patient and family." Further review of the record did not indicate the MSW and SC contributed to the development of the patient's POC. A review of Patient 7's admission record indicated the patient was admitted to the HA on 6/18/22, with a diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. A review of Patient 7's medical record titled, "POC/IDG review", dated 6/18/22, indicated "IDG discussion/update comprehensive assessment review: SC was informed of new admission. SC will call the patient/family for initial evaluation within 5 days of SOC to identify emotional and spiritual support to patient and family. LCSW was informed of new admission. LCSW will call the patient/family for initial evaluation within 5 days of SOC to identify emotional and psychosocial support to patient and family." Further review of the record did not indicate the MSW and SC contributed to the development of the POC. A review of Patient 8's admission record indicated the patient was admitted to the HA on 6/18/22 with a diagnosis of heart failure (heart muscle does not pump blood as well as it should). A review of Patient 8's medical record titled "POC/IDG review", dated 6/18/22, indicated "IDG discussion/update comprehensive assessment review: SC will call the patient/family for initial evaluation within 5 days of SOC to identify spiritual needs to patient/family. LCSW will call the patient/family for initial evaluation within 5 days of SOC to identify psychosocial and emotional concerns to patient/family." Further review of the record did not indicate the MSW and SC contributed to the development of the POC. A review of Patient 10's admission record indicated the patient was admitted to the HA on 10/4/21 with a diagnosis of malignant neoplasm of uterus (uterine cancer). A review of Patient 10's medical record titled, "POC/IDG review", dated 10/4/21, indicated "IDG discussion/update comprehensive assessment review: Chaplain visits-initial assessment within 5 days to provide spiritual support to patient and family. MSW visits-initial assessment within 5 days to provide psychosocial support to patient and family." Further review of the record did not indicate the MSW and SC contributed to the development of the POC. A review of Patient 11's admission record indicated the patient was admitted to the HA on 7/20/21 with a diagnosis of acute kidney failure. A review of Patient 11's medical records and electronic medical record did not indicate any records the IDG team met to discuss and develop the plan of care for Patient 11. During an interview on 7/19/22, at 12:15 p.m., the Director of Patient Care Services (DPCS) stated the nurse and the doctor create the plan of care once the initial nursing assessment is done. The DPCS stated the participants of the interdisciplinary group (IDG) were the doctor, registered nurse, medical social worker (MSW), and the spiritual counselor (SC). A review of facility's policy titled, "Interdisciplinary Group (IDG) Membership and Responsibilities" revised November 2020 indicted, "The hospice IDG membership includes at a minimum: Physician, Registered Nurse, Social Worker, and Pastoral or other counselor ... The IDG responsibilities include but are not limited to: A. Consulting with the patient's attending physician (if any), completes the initial comprehensive assessment within five (5) calendar days after the election of hospice care. B. Participation in the establishment of the plan of care for each patient admitted to the hospice services.

Based on interview and record review, the Hospice Agency (HA) failed to ensure all care and services follow the individualized plan of care regarding frequency of licensed nurse home visits for three of 11 sampled patients (Patient 6, 7, and 8). This deficient practice can result to poor-quality care provided to all the patients under the agency's care and can affect each patient's quality of life. Findings: 1. A review of Patient 6's admission record indicated the patient was admitted to the HA on 5/20/22, with a diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. During an interview on 7/19/22, at 12:55 p.m., the Director of Patient Care Services (DPCS) stated the agency's process for missed visit was as follows: "We ask purpose of missed visit, we make an appointment to make up the visit that same week. It is very important to notify the patient and reschedule so they do not feel neglected. The day the visit is missed, we document it. The purpose of the missed visit and the interventions taken to reschedule the visit. Sometimes we tell the doctor because this is a nursing thing." During an interview on 7/19/22, at 1:00 p.m., the DPCS stated, "Within 24 to 48 hours the nursing note should be in the record. We try our best to put it in. If it is not documented, the visit didn't occur." A review of Patient 6's record titled, "POC Summary", for certification period 5/20/22 to 8/17/22, indicated " ...14. Frequency of visits LVN (licensed vocational nurse) 1 per week and 1 prn (as needed) visits ..." A review of Patient 6's record did not indicate an LVN visited the patient on the week of 6/26/22 and 7/3/22. Further review of the record did not indicate the reason for the missed visit or interventions by agency to reschedule the missed visit. 2. A review of Patient 7's admission record indicated the patient was admitted to the HA on 6/18/22, with a diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. During an interview on 7/19/22, at 1:25 p.m., the DPCS ... "I don't know why there was no LVN notes on the record." A review of Patient 7's record titled, "POC Summary", for certification period 6/18/22 to 9/15/22, indicated " ...14. Frequency of visits LVN of 1 per week and 1 prn (as needed) visits ...". Further review of the record did not indicate LVN visits for the certification period, the reason for the missed visit, or interventions by agency to reschedule the missed visit. A review of Patient 8's admission record indicated the patient, who lived in Sacramento, California, was admitted to the HA on 6/18/22 with a diagnosis of heart failure (heart muscle does not pump blood as well as it should). During an interview on 7/19/22, at 1:25 p.m., the DPCS stated " ...we do not have an RN (registered nurse) in the Sacramento area." 3. A review of Patient 8's record titled,"POC Summary", for certification period 7/12/22 to 10/9/22, indicated " ...14. Frequency of visits RN 1 per week and 2 prn (as needed) visits ..."Further review of the record did not indicate RN visits for the certification period, the reason for the missed visit, or interventions by agency to reschedule the missed visit. A review of facility's policy titled, "Missed Visits" revised November 2020 indicated, " ... A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record".

Based on interview and record review, the Hospice Agency (HA) failed to educate Care Giver (CG1) for one of eleven sampled patients (Patient 1) on how to properly perform wound care services. This failure had the potential to result in placing Patient 1 at risk for not receiving proper wound care which could delay the healing process and at risk for developing an infection. Findings: A review of Patient 1's (P1) face sheet indicated P1 was a 56-year-old male, start of care (SOC) date of 4/29/2022 with an admitting diagnosis of Cerebral infarction due to thrombosis of precerebral artery (stroke). A review of Patient 1's (P1) Plan of Care (POC) Summary indicated P1 had an order for wound dressing every day, cleanse with normal saline for irrigation and betadine (used on the skin to treat or prevent skin infection). During an interview on 7/15/2022 at 11:40 a.m. with P1's Care Giver (CG1), CG1 stated that he changes P1's right great toe wound dressing every day. CG1 stated that he did not receive instructions on how to change the dressing or cleanse the wound. CG1 stated, "I see them do it, so I copy them." During an interview on 7/15/2022 at 11:55 a.m. with License Vocational Nurse (LVN1), LVN1 stated she did not have P1's POC with her. LVN1 stated, "They should have it in the binder. The caregivers and nurses need to check it because the care that is being given is written there." A review of facility's policy titled, "Administration and Documentation of Medications" revised November 2020 indicated, "The hospice nurse will provide instruction to the patient on a continuing basis." A review of facility's policy titled, "Admission Criteria and Process" revised November 2020 indicated that the hospice agency, "13. The hospice registered nurse will educate the family in techniques for providing care." A review of facility's policy titled, "Monitoring Patient's Response/Reporting to Physician" revised November 2020 indicated, "During each hospice visit, the clinician will monitor the patient's response to care against established goals including, but not limited to: C. Teaching." A review of facility's policy titled, "The Plan of Care" revised November 2020 indicated, "The care provided to the patient must be in accordance with the plan of care ... The plan of care will identify the patient's needs and services to meet those needs ... As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through with ... Patient and family/caregiver educational needs and assessed of their ability to learn and understand teaching ... Care provided to the patient must be in accordance to the plan of care." A review of facility's policy titled, "Educational Resources" revised November 2020 indicated, "1. Hospice will provide educational resources that include but will not be limited to: B. Written instructions developed by the hospice pertinent to services, pain and symptom management, treatments, medications, etc..." A review of facility's "Licensed Practical/Vocational Nurse - Job Title/Position" revised November 2020 indicated, "Assess ad provide patient and family/caregiver education and information pertinent to diagnosis and self-plan of care."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the comfort kit (medications used to alleviate symptoms during the end-of-life process) was available for one of 11 sampled patients (Patient 6). This failure had the potential to affect the quality of life for Patient 6 by not having comfort kit available to treat symptoms during the end-of-life process. Findings: A review of Patient 6's admission record indicated the patient was admitted to the HA on 5/20/22, with a diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. During a concurrent observation and interview during the home visit on 7/15/22, at 9:30 a.m., the Licensed Vocational Nurse (LVN), was observed looking for the comfort kit in Patient 6's refrigerator. The LVN stated "Ill check with pharmacy and order them again." The LVN stated comfort kit was not ordered for the patient. The LVN stated "I just ordered it." During an interview on 7/19/22, at 12:45 p.m., the Director of Patient Care Services (DPCS) stated " ... The comfort kit should be given on admission. It is very important because are dealing with hospice. We never know if they need it right away, that's why it should be there. It is to treat their symptoms while they are dying. So they have a peaceful passing." A review of facility's policy titled, "Hospice Comfort Kits" updated December 31, 2021 indicated, "All hospice patients not residing in a nursing home will receive a comfort kit containing emergency medication as ordered by the patient's physician or the Hospice Medical Director ... Comfort Kit medication will be observed directly by the hospice nurse during the first visit of the week to assure that the kit has not expired and is intact and available for use".

Based on interview and record review, the Hospice Agency (HA) failed to ensure all care services furnished followed individualized plans of care established be the interdisciplinary team (IDT) by not conducting home visits as indicated in the plan of care for three of 11 sampled patients (Patients 1, 4, and 5). This deficient practice resulted in the patients not receiving care/services from the home visits and placed the patients at risk for not receiving care/services when they needed. Findings: A review of Patient 1's (P1) face sheet indicated P1 was a 56-year-old male, start of care (SOC) date of 4/29/2022 with an admitting diagnosis of Cerebral infarction due to thrombosis of precerebral artery (stroke). A review of Patient 1's (P1) Plan of Care (POC) Summary indicated P1 was scheduled to have Home Aide (HA) visits twice a week (2x/wk), Skilled Nursing (SN) visits once a week (1x/wk), Medical Social Worker (MSW) and Spiritual Counselor (SC) initial assessment within 5 days, Registered Nurse (RN) initial evaluation then every 14 days. Volunteer services offered but declined. There was nothing written under diet. A concurrent interview and record review on 7/19/2022 at 1 p.m. with DPCS, of P1's electronic medical record (EMR) indicated P1 had no Skilled Nursing (SN) visit notes documented for the weeks of 6/5/2022 and 7/3/2022. It also indicated P1 had no Certified Home Health Aide (CHHA) visit notes documented since the beginning of the current benefit period starting on 4/29/2022. A review of Patient 4's (P4) face sheet indicated P4 is a 77-year-old female, start of care (SOC) date of 6/1/2022 and an admitting diagnosis of Hypertensive heart failure. A review of Patient 4's (P4) Plan of Care (POC) Summary indicated P4 was scheduled to have Skilled Nursing (SN) visits once a week (1x/wk), Medical Social Worker and Spiritual Counselor initial assessment within 5 days, and Registered Nurse (RN) initial evaluation then every 14 days. Volunteer and Home Aide (HA), services offered but declined. There was nothing written under diet or frequency of visits. A concurrent interview and record review on 7/19/2022 at 1 p.m. with DPCS, of P4's electronic medical record (EMR) indicated P4 had no SN visit notes documented for the weeks of 6/5/2022 and 7/3/2022. A review of Patient 5's (P5) face sheet indicated P5 is an 81-year-old female, start of care (SOC) date of 6/16/2022 and an admitting diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs). P5's home address in Camarillo California in Ventura County. A review of Patient 5's (P5) Plan of Care (POC) Summary indicated P5 was scheduled to have Home Aide (HA) visits twice a week (2x/wk), Skilled Nursing (SN) visits once a week (1x/wk), Medical Social Worker (MSW) and Spiritual Counselor (SC) initial assessment within 5 days, Registered Nurse (RN) initial evaluation then every 14 days. Volunteer services offered but declined. A concurrent interview and record review on 7/19/2022 at 1 p.m. with DPCS, of P5's electronic medical record (EMR) indicated P5 had no SN visit notes documented for the week of 6/19/2022 and no CHHA visit notes documented since the beginning of the current benefit period starting on 6/16/2022. An interview on 7/19/2022 at 12:15 p.m. with the Director of Patient Care Services (DPCS), DPCS stated, "We ask the nurse the purpose of the missed visit, we call the patient to notify them of the missed visit. We will visit them within that week. We documented it on as a missed visit, then we call the patient. We documented the purpose of the missed visit. We documented the interventions and attempts, sometimes they are agreeable to them after we tell them the reasons why there will be a missed visit. Sometimes we tell the doctor, not all the time because it's a nursing thing". A review of facility's policy titled, "Missed Visits" revised November 2020 indicated, "Missed visits will be communicated to the interdisciplinary Group (IDG) in the IDG Meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record". A review of facility's "Licensed Practical/Vocational Nurse - Job Title/Position" revised November 2020 indicated, "2. Implement current nursing practice following a comprehensive assessment and the plan of care. 3. Provide accurate and timely documentation of patient services to reflect the plan of care."

Based on interview and record review the Hospice Agency (HA) failed to ensure the care giver (CG 1) of two out of 11 sampled patients (Patients 1 and 2) was provided with the patient's plan of care (POC) information regarding the services/care being provided by the HA. This failure had the potential to result in the patients not receiving the services/care as indicated in their individualized POC. Findings: A review of Patient 1's (P1) face sheet indicated P1 was a 56-year-old male, start of care (SOC) date of 4/29/2022 with an admitting diagnosis of Cerebral infarction due to thrombosis of precerebral artery (stroke). A review of Patient 1's (P1) Plan of Care (POC) Summary indicated P1 was scheduled to have Home Aide (HA) visits twice a week (2x/wk), Skilled Nursing (SN) visits once a week (1x/wk), Medical Social Worker (MSW) and Spiritual Counselor (SC) initial assessment within 5 days, Registered Nurse (RN) initial evaluation then every 14 days. Volunteer services offered but declined. There was nothing written under diet. A review of Patient 2's (P2) face sheet indicated P2 is a 65-year-old male, start of care (SOC) date of 3/1/2022 and an admitting diagnosis of Atherosclerotic Heart Disease of native coronary artery without angina pectoris (the buildup of plaque inside your arteries). A review of Patient 2's (P2) Plan of Care (POC) Summary indicated P2 was scheduled to have Home Aide (HA) visits twice a week (2x/wk), Skilled Nursing (SN) visits once a week (1x/wk), and Registered Nurse (RN) initial evaluation then every 14 days. Volunteer and Medical Social Worker (MSW) services offered but declined. During an interview on 7/15/2022 at 11:40 a.m. with P1 and P2's Care Giver (CG1), CG1 stated that there is no POC for P1 or P2. CG1 stated, "I don't know what that is. I've never been given or told what a plan of care is." In an interview on 7/15/2022 at 11:55 a.m. with License Vocational Nurse (LVN1), LVN1 stated she did not have P1 or P2's POC with her. LVN1 stated, "They should have it in the binder. The caregivers and nurses need to check it because the care that is being given is written there." A review of facility's policy titled, "Admission Criteria and Process" revised November 2020 indicated that the hospice agency, "A plan of care will be developed by the attending physician, the Medical Director, and the hospice team." A review of facility's policy titled, "The Plan of Care" revised November 2020 indicated, "The care provided to the patient must be in accordance with the plan of care ... The plan of care will identify the patient's needs and services to meet those needs ... As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through with ... Care provided to the patient must be in accordance to the plan of care."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation on Quality Assessment and Performance Improvement (QAPI) program was met as follows: 1. The HA failed to provide evidence that quality assessment and performance improvement (QAPI, a coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI), which are critical to improving the quality of life, and quality of care and services delivered in a healthcare facility) system was formulated. (Refer to L560) 2. The HA also failed to ensure its program objectives, patient care disciplines, description of how the program would be administered and coordinated, methodology for monitoring and evaluating the quality of care, priorities for resolution of problems, monitoring to determine effectiveness of action, oversight responsibility reports to governing body, and documentation of the review of its own QAPI program were implemented. (Refer to L560) 3. The HA failed to provide evidence that a governing body was maintained to ensure full responsibility for the operation of the program; evaluate annually, the overall performance of the agency and ensure a policy for its governing body was formulated. (Refer L574) The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of a quality health care in a safe environment.

Based on interview and record review, the Hospice Agency (HA) failed to provide evidence that quality assessment and performance improvement (QAPI, a coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI), which are critical to improving the quality of life, and quality of care and services delivered in a healthcare facility) system was formulated. The HA also failed to ensure its program objectives, patient care disciplines, description of how the program would be administered and coordinated, methodology for monitoring and evaluating the quality of care, priorities for resolution of problems, monitoring to determine effectiveness of action, oversight responsibility reports to governing body, and documentation of the review of its own QAPI program were implemented. These deficient practices resulted in the inability of the agency to identify issues, improve health outcomes, patient safety, and quality patient care. Findings: During an interview on 7/19/2022, at 2:00 p.m., the Director of Patient Care Services (DPCS) stated the agency did not have a QAPI program for 2022 and did not know the reason why. The DPCS stated it was important to have a QAPI program because the agency needed to know what it needed to improve on. A review of the HA's policy and procedure titled, "Addendum 3-001.B Sample QAPI Plan", dated November 2020, indicated "The purpose of the hospice QAPI Plan is to provide a strategy for the systematic organization-wide implementation of quality assessment and performance improvement activities. This will ensure that the organization is providing appropriate, high-value, effective and efficient services in accordance with its mission and current standards of practice."

Based on interview and record review, the Hospice Agency (HA) failed to provide evidence that a governing body was maintained to ensure full responsibility for the operation of the program; evaluate annually, the overall performance of the agency and ensure a policy for its governing body was formulated. These deficient practices resulted in the inability of the agency to identify issues, improve health outcomes, patient safety, and quality patient care. Findings: During an interview on 7/19/2022, at 2:00 p.m., the Director of Patient Care Services (DPCS) stated the agency did not have a QAPI program for 2022. The DPCS stated "members of the QAPI should be the doctor, nurses and everyone who works here". The agency did not provide evidence a governing body was established. A review of the HA's policy and procedure titled, "Addendum 3-001.B Sample QAPI Plan", dated November 2020, indicated "The Governing Body is ultimately responsible for the QAPI Plan and for ensuring: That the QAPI Plan is ongoing, implemented and maintained ...".

Based on interview and record review, the hospice agency failed to ensure the Condition of Participations for Clinical Records were met as follows: 1. Failed to follow its policy and procedure to ensure clinical records were not modified (make partial or minor changes) for six of 11 sampled patients, Patients 6, 7, 8, 9, 10 and 11. The changes made can result to inaccurate documentation of the clinical records which can affect the patients plan of care and interventions and the quality of services provided by the agency to all the patients under their care. (Refer to L 679) 2. Failed to ensure the patients' clinical records were safeguarded against unauthorized user for two of 11 sampled patients, Patients 6 and 7. This access by the unauthorized user can violate the patients rights to privacy and confidentiality. (Refer to L680) The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of a quality health care in a safe environment.

Based on interview and record review, the hospice agency failed to ensure clinical records were not modified (make partial or minor changes) for six of 11 sampled patients, Patients 6, 7, 8, 9, 10 and 11. This failure had the potential to result in inaccurate documentation of the clinical records which can affect the patients plan of care and interventions and the quality of services provided by the agency to all the patients under their care. Findings: During a clinical record review on 7/19/2022 at 1 p.m., Patient 6's admission record indicated Patient 6 was admitted on 5/20/2022, with diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. The electronic medical record for Patient 6 titled "Audit Log" (a document that records an event in an information (IT) technology system. It documents what resources were accessed, audit log entries usually include destination and source addresses, a timestamp and user login information), dated 7/14/22 to 7/19/22, indicated that on 7/15/22 at 10:27 a.m. to 7/15/22 to 11:08 a.m. and 7/18/22 12:35 p.m., the clinical records were modified. A review of Patient 7's admission record indicated Patient 7 was admitted on 6/18/2022, with a diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. The electronic medical record for Patient 7 titled "Audit Log", dated 7/14/22 to 7/19/22, indicated that on 7/15/22 at 11:56 a.m. to 7/15/22 at 12:12 p.m. the clinical records were modified. A review of Patient 8's admission record indicated Patient 8 was admitted on 6/18/2022 with a diagnosis of heart failure (heart muscle does not pump blood as well as it should). The electronic medical record for Patient 8 titled "Audit Log", dated 7/14/22 to 7/19/22, indicated that on 7/14/22 7:30 p.m., the clinical records were modified. A review of Patient 9's admission record indicated Patient 9 was admitted on 9/8/2021 with a diagnosis of heart disease. The electronic medical record for Patient 9 titled "Audit Log", dated 7/14/22 to 7/19/22, indicated that on 7/14/22 6:52 p.m., the clinical records were modified. A review of Patient 10's admission record indicated Patient 10 was admitted to the HA on 10/4/21 with a diagnosis of malignant neoplasm of uterus (uterine cancer). The electronic medical record for Patient 10 titled "Audit Log", dated 7/14/22 to 7/19/22, indicated that on 7/18/22 3:53 p.m., the clinical records were modified. A review of Patient 11's admission record indicated Patient 11 was admitted to the HA on 7/20/21 with a diagnosis of acute kidney failure. The electronic medical record for Patient 11 titled "Audit Log", dated 7/14/22 to 7/19/22, indicated that on 7/18/22 9:30 a.m., the clinical records were modified. During an interview on 7/19/2022, at 1:40 p.m., the Director of Patient Care Services (DPCS) stated she had been making changes to medical records. The DPCS stated "That is not right, I know. We are not supposed to be doing that." The DPCS did not provide an explanation for the reason why she was making changes to medical records. During an interview on 7/19/20,22, at 1:48 p.m., the office staff (OS) stated he had made changes to Patient 6's medical record because he was trying to help. The OS stated he read the notes entered on other dates and copied them into the Interdisciplinary Group (IDG, team members from different disciplines who work collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) notes for 7/6/2022. The OS also stated he does not participate in any IDG meetings, and admitted he entered notes for nursing in the IDG note for 7/6/2022. When asked, OS stated, "to tell you the truth, I know it's my fault not to do that. I should not do that, because I am not a nurse. I know it's not right. I just wanted to make the documentation complete". A review of facility's policy titled, "Person or Entity Authentication", revised November 2020, indicated, "To safeguard ePHI, it is important to corroborate that ePHI has not been altered or destroyed in an unauthorized manner as required pursuant to the HIPAA Security Regulations." The Hospice Agency "will take appropriate steps to protect the integrity of ePHI that it creates, receives, maintains or transmits from unauthorized modification".

Based on interview and record review, the hospice agency failed to follow its policy and procedure to ensure the patients' clinical records were not accessed by a non-clinical (employees that do not provide patient care) personnel, for two of 11 sampled patients, Patients 6 and 7. This deficient practice had the potential to violate the patients rights to privacy and confidentiality. Findings: During a clinical record review on 7/19/2022 at 1 p.m., Patient 6's admission record indicated Patient 6 was admitted on 5/20/2022, with diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. The electronic medical record for Patient 6 titled "Audit Log" (a document that records an event in an information (IT) technology system. It documents what resources were accessed, audit log entries usually include destination and source addresses, a timestamp and user login information), dated 7/14/22 to 7/19/22, indicated that on 7/15/22 at 10:27 a.m. to 7/15/22 to 11:08 a.m., 7/18/22 12:35 p.m., the clinical records were modified by an office staff (OS). A review of Patient 7's admission record indicated Patient 7 was admitted on 6/18/2022, with a diagnosis of hypertensive heart disease (heart problems due to high blood pressure) without heart failure. The electronic medical record for Patient 7 titled "Audit Log", dated 7/14/22 to 7/19/22, indicated that on 7/15/22 at 11:56 a.m. to 7/15/22 at 12:12 p.m. the clinical records were modified by OS. During an interview on 7/19/20,22, at 1:48 p.m., the OS stated he had made changes to Patient 6's medical record because he was trying to help. The OS stated he read the notes entered on other dates and copied them into the Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) notes for 7/6/2022. The OS also stated he does not participate in any IDG meetings, and admitted he entered notes for nursing in the IDG note for 7/6/2022. When asked, OS stated, "to tell you the truth, I know it's my fault not to do that. I should not do that, because I am not a nurse. I know it's not right. I just wanted to make the documentation complete". A review of facility's policy titled, "Access to Information", revised November 2020, indicated, "Access to patient information files (clinical/service record and billing) will be limited to organization personnel involved in the care of the patient. It also indicated that office personnel will only have access to information on those patients to which they are actively providing service, such as working on bills, following up on complaints, etc."