Every finding on record at Constant Hospice Care, Inc.

Observed in Record Review. In 1 of 3 patient records reviewed, the organization failed to provide care, treatment, or services for each patient. During record review for RRNHV#3, the Hospice Nurse Surveyor observed the patient had orders to check blood sugars for symptoms of hyperglycemia and hypoglycemia. There was no documentation that the nursing assessments included symptoms of hyperglycemia/ hypoglycemia. This was discussed and reviewed with the Hospice Team.

Observed in Tracer Activities. During review of the organization emergency plan introduction and review of the organization HVA, it was noted lack of patient education information related to potential disasters identified by the organization. The emergency plan (EP) described in the introduction with the following: natural disasters include [wild] fire, floods and earthquakes. Man made disasters include terrorism and active shooter. Agency disasters include equipment and power failures. The patient education lacked information to assist families with mitigation and preparedness activities that included floods, terrorism and power failures. This was discussed with the leadership.

Observed in Record Review. In 2 of 14 patient records reviewed, During RR#2 Live Discharge it was noted the patient was discharged due to assessments by the IDG of an extended prognosis. Although discharge planning was documented there is no documentation of a Notice of Non-Medicare Coverage (NOMNC) signed at least 2 days prior to the d/d date the beginning of April 2024. During RR#3 it was noted the patient was discharged due to an extended prognosis. Although discharge planning was documented there was lack of a signed NOMNC at least 2 days prior to the discharge date in April 2024. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During HV#1 record review it was noted during the LVN visit the middle of March 2024 the following: Pt daughter did mention that [the patient] was sick on Sunday and had episode of diarrhea and had a fever. Tylenol was given to help with fever. This update was not added to the RN comprehensive assessment at the next IDG the end of March 2024. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During HV#1 record review it was noted oxygen was added to the POC as an environmental issue with the goals and interventions documented the middle of March 2024. The patient did not have an order for oxygen therapy at that time with no documentation of oxygen therapy in March 2024. This was discussed with the organization leadership.

Observed in Record Review. In 2 of 14 patient records reviewed, During HV#2 record review it was noted 4 out of 15 goals on the POC were not individualized or measurable and not updated after the middle of March 2024, as follows: The patient will have adequate food and fluids as tolerated or desired in 2 weeks. Patient will be comfortable for the next 2 weeks of Hospice care. Patient needs will be met on a day to day basis as expressed through non-verbal cues for the next 2 weeks of hospice care. The patient will minimize seizure activity and protect self from injury for the next 2 weeks of Hospice care. During RR#3 it was noted 2/10 goals were not individualized or measurable and were not updated after the middle of March 2024: Pt will maintain optimum peripheral circulation. Patient will experience decrease symptoms of pain during the next 14 days. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During RR#2 Live Discharge it was noted an order for oxygen therapy was not updated after the middle of March to reflect parameters for oxygen flow changes. The order was: Oxygen therapy at 2 liters per minute via nasal cannula as needed for Shortness of breath. May increase to 4 liters if 2 liters is ineffective.. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During HV#1 record review it was noted the chaplain performed a phone visit the end of March 2024 and another phone visit the middle of April 2024. The POC was not updated to reflect the use of phone calls as a type of visit. This was discussed with the organization leadership.

Observed in Record Review. In 1 of 14 patient records reviewed, During HV#2 record review it was noted an order on the POC to monitor and measure blood pressure in both hands, using a cuff and proper techniques in terms of measuring blood pressure. There was lack of documentation in SN notes to date from end of January 2024 of BP monitoring in both hands or bilateral arms. This was discussed with the organization leadership.

Observed in Leadership Session.  There was no evidence that the governing body and leadership had established requirements to support patient care treatment and services as evidenced by lack of a contract with a skilled nursing facility (SNF) for the provision of GIP and respite services resulting in a CLD at 418.108 and 418.100. This was discussed with the Administrator designee who has been pursuing area SNFs for a contract to provide organization patients with GIP and respite services when needed.

Observed in Emergency Management Session. In 14 of 14 patient records reviewed, During review of the organization emergency plan introduction and review of the organization HVA, it was noted lack of patient education information related to potential disasters identified by the organization. The emergency plan (EP) described in the introduction with the following: natural disasters include [wild] fire, floods and earthquakes. Man made disasters include terrorism and active shooter. Agency disasters include equipment and power failures. The patient education lacked information to assist families with mitigation and preparedness activities that included wild fires, floods, terrorism and power failures. This was discussed with the leadership.

Observed in Document Review. During review of the DME contract it was noted lack of a Medicare DMEPOS certificate in the file. According to the DME company, the person who has access to the information is not available. This was discussed with the organization leadership.

Observed in Document Review. It was noted the organization did not have a contract with a Medicare or Medicaid (Medi-Cal) facility for inpatient care and respite care. In discussion with the Administrator designee, the organization is actively pursuing area SNFs to obtain a contract.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Conditions of Participation (the terms healthcare organizations must meet to participate in federally funded healthcare programs) regarding Patients Rights was met as follows: --- The HA failed to inform three of 13 sampled patients (Patient 1, Patient 2, and Patient 7) about the services the HA provided and the limitations on those services. (Refer to L519) The cumulative effect of this systemic practice resulted in the failure of the HA to deliver statutorily (written law) mandated Federal compliance for Patients Rights to ensure Patient 1, Patient 2, and Patient 3s rights were not violated and received the highest quality of hospice care.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to inform three of 13 sampled patients (Patient 1, Patient 2, and Patient 7) about the services the HA provided and the limitations of these services. This deficient practice resulted for Patient 1, Patient 2, and Patient 7 not to be informed about the purpose of the hospice care services and had the potential to affect the patients overall care. --- Findings: c. During a review of Patient 7s demographics ((identifying information such as patients name, date of birth and address, along with insurance information) indicated a start of care (SOC) date of 11/1/2023 with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with early onset. During a review of Patient 7's Plan of Care (POC) Summary form indicated an order, dated 11/1/2023, for the licensed vocational nurse (LVN) frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to do an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. Spiritual counselor (SC), social worker (MSW), and hospice aide (CHHA) services were offered but declined. During a joint home visit, on 3/12/2024 at 4:10 p.m. with the LVN 2 at Patient 7s residence, Patient 7 was observed sitting on a wheelchair, was awake, alert and oriented x 1 (to person only), accompanied by a family member (FM 1). During an interview on 3/12/23 at 4:22 p.m., FM 1 stated no doctor or nurses told her that Patient 7 had six months or less to live and did not know that hospice care was for those patients with terminal illness. FM 1 further stated Patient 7 was not dying, and if ever Patient 7 needed medical emergency, she would not hesitate to call 911 (universal emergency number throughout the United States to request emergency assistance). During a review of the agencys policy and procedure titled, ";Rights/Responsibilities", revised November 2022, indicated each patient will be an active, informed participant in his/her plan of care. The patient, authorized decision-maker or legal representative will be informed during the initial assessment visit, in advance of furnishing care, of the hospice philosophy and program of care and the organizations mission and care and services provided directly or through contractual arrangements. a. A review of Patient 1's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated the HA admitted Patient 1 on 11/1/2023, with a diagnosis of hypertensive heart disease (a heart problems that occur because of high blood pressure that is present over a long time) with heart failure (the heart cannot pump enough blood to meet the body's needs). During a joint home visit on 3/12/2024, at 1:45 p.m., with LVN 1, Patient 1 was observed walking in steady gait without using an assistive device. During an interview on 3/12/24, at 2 p.m., when asked if she was informed about the purpose of the hospice care services, she stated had no idea what hospice services was about. She also stated the agency would send a nurse to come visit every week to take her vital signs but the visiting nurse came and visited only once during the initial (first) visit. Patient 1 further stated that the agency offered to provide free medical supplies such as lotions, incontinent pads and shampoo upon patient admission to their hospice service. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 11/8/2023, with a terminal diagnosis of heart disease ( heart condition that include diseased vessels, structural problems, and blood clots). A review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 1/17/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to two visits per week, registered nurse (RN) to conduct initial evaluation within five days of admission then every recertification. On 3/12/2024, at 12 p.m., a joint home visit was conducted at Patient 2's residence. Patient 2 was observed walking with a steady gait without the use of an assistive device. On 3/12/2024, at 12:30 p.m., during an interview with Patient 2, when she was asked if the hospice agency informed the patient and family members about the purpose of the hospice care services, she stated the hospice service will provide a nurse to visit every week to take her blood pressure and provide her with her prescribed medications. During an interview with the director of patient care services (DPCS) on 3/14/2024, at 12 p.m., the DPCS stated the visiting nurse should have informed the patient regarding hospice services upon their admission.

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of the Patient was met as follows: 1. The HA failed to ensure the interdisciplinary group completed the comprehensive assessment no later than five calendar days after election of hospice care for four of 13 sampled patients (Patient 7, Patient 10, Patient 11, and Patient 12). (Refer to L523) 2. The HA staff failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for four of 13 sampled patients (Patient 1, Patient 2, Patient 7, and Patient 12). (Refer to L524) 3. The hospice agency failed to maintain an accurate, current medication profile for three of 13 sampled patients (Patient 1, Patient 2, and Patient 7). (Refer to L530) 4. The HA failed to provide initial bereavement assessment for seven of 13 sampled patients (Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). (Refer to L531) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulation for Initial and Comprehensive Assessment of the Patient to ensure the highest quality of care are being provided to patients certified to receive the Medicare hospice benefits.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group completed the comprehensive assessment no later than five calendar days after election of hospice care for four of 13 sampled patients (Patient 7, Patient 10, Patient 11, and Patient 12). This deficient practice had the potential to result in patients needs not being identified. --- Findings: a. During a review of Patient 7s demographics ((identifying information such as patients name, date of birth and address, along with insurance information) indicated a start of care (SOC) date of 11/1/2023 with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with early onset. During a review of Patient 7's Plan of Care (POC) Summary form indicated an order, dated 11/1/2023, for the licensed vocational nurse (LVN) frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to do an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. Spiritual counselor (SC), social worker (MSW), and hospice aide (CHHA) services were offered but declined. During a review of Patient 7's Comprehensive Nursing 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), dated 11/01/2023, indicated Patient 7 was awake, alert, oriented x 1 (to person only), had regular pulse (heart rate), had normal respirations (breathing) and clear lung sounds. The assessment was electronically signed by the Director of Patient Care Services (DPCS), on 2/09/2024, or more than 3 months after the assessment was conducted. b. During a closed record review of Patient 10s demographics indicated a start of care date of 11/18/2023, with a terminal diagnosis of cerebral infarction (also called a stroke, it occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to embolism (a blood clot that blocks the blood supply to an organ in the body) of right middle cerebral artery (an artery that supplies blood to the brain). During a review of Patient 10's POC Summary form indicated an order, dated 11/18/2023, for the skilled nurse (SN) frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to conduct an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. SC, MSW, and CHHA services were offered but declined. During a review of Patient 10's Comprehensive Nursing Assessment, dated 11/18/2023, indicated Patient 10 was awake, alert, oriented x 2 (to place and person), had regular pulse, had normal respirations and was bedbound. The assessment was completed and signed by a licensed vocational nurse (LVN 1), on 2/06/2024, or more than 2 1/2 months after the assessment was conducted. c. During a closed record review of Patient 11s demographics indicated a start of care date of 11/1/2023 with a terminal diagnosis of myocarcardial infarction (or heart attack, a blockage of blood flow to the heart muscle) type 2. During a review of Patient 11's POC Summary form indicated an order, dated 11/1/2023, for the skilled nurse frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to conduct an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. SC, MSW, and CHHA services were offered but declined. During a review of Patient 11's Comprehensive Nursing Assessment, dated 11/1/2023, indicated Patient 11 was awake, alert, oriented x 3 (to time, place, and person), had regular pulse, had normal respirations, and had no cardiac-related pain. The assessment was signed and completed by the DPCS on 3/11/2024, or more than four months after the assessment was conducted. d. During a closed record review of Patient 12s demographics indicated a start of care date of 12/5/2023 with a terminal diagnosis of Alzheimers disease, unspecified and Patient 12 was discharged on 1/03/2024 because he declined further services. During a review of Patient 12's clinical record indicated that there was no initial comprehensive nursing assessment, spiritual assessment, and psychosocial assessment that was conducted. During a concurrent interview and record review with the DPCS, on 3/14/2024 at 12:50 p.m., the DPCS stated comprehensive assessment should be completed, documented, and signed within 5 days from the start of hospice care and service. DPCS stated the comprehensive nursing assessment should be completed and signed by a registered nurse and not by a licensed vocational nurse. DPCS confirmed Patient 7, Patient 10, Patient 11, and Patient 12s comprehensive assessment was not completed within 5 days from the start of care of hospice service. During a telephone interview with LVN 1, on 3/14/2023 at 1:30 p.m., when asked if she signed and completed Patient 10s initial comprehensive assessment, LVN 1 stated she did. When asked if it was within her scope of practice to sign and complete the comprehensive nursing assessment, LVN 1 stated, ";I get mixed information about it that an LVN can, and others say we cannot. Im fairly new to hospice." During a review of the agencys policy and procedure titled, ";Comprehensive Assessment," revised November 2022, indicated a comprehensive patient assessment will be performed by the hospice IDG no later than 5 calendar days after the election of hospice care in consultation with attending physician. During a review of the agencys policy and procedure titled, ";Psychosocial Assessment," revised November 2022, indicated an in-depth psychosocial assessment will be completed by a qualified hospice social worker or hospice registered nurse. The assessment includes but is not limited to coping with and adjusting to the patients terminal illness, making final arrangements, reaction to the terminal illness and subsequent bereavement needs, and social and financial needs. During a review of the agencys policy and procedure titled, ";Spiritual Assessment," revised November 2022, indicated an in-depth spiritual assessment will be completed for each patient/family by the Hospice Chaplain. The assessment will include, but not limited to, evaluation of the following: 1. Coping with and adjusting to the patients terminal illness 2. Assessing bereavement needs 3. Religious and/or spiritual reactions to terminal illness

Based on observation, interview, and record review, the Hospice Agency (HA) staff failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for four of 13 sampled patients (Patient 1, Patient 2, Patient 7, and Patient 12). This deficient practice resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential to result in the patients not receiving appropriate healthcare services that could affect their quality of life. --- Findings: c. During a review of Patient 7s demographics ((identifying information such as patients name, date of birth and address, along with insurance information) indicated a start of care (SOC) date of 11/1/2023 with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with early onset. During a review of Patient 7's Comprehensive Recertification Nursing 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), dated 1/29/2024, indicated Patient 7 was awake, alert, oriented x 1 (to person only, had no cardiac-related pain, normal respirations (breathing), and was dependent on cane or walker. During a review of Patient 7's "Physician Certification for Hospice Benefit" (or CTI, Physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the 2nd benefit period from 1/30/2024 to 4/28/2024, the Medical Director indicated Patient 7 has a life expectancy of six months or less if the terminal illness ran its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 7 had a life expectancy of six months or less if the terminal illness runs its normal course. The "Certifying Physician Summary" section indicated Patient 7s speech impairment has worsened limited to use of a single intelligible word in an average day, had decreased weight, and was eligible for hospice recertification. The CTI was not signed by the Medical Director (Physician 1). During a review of Patient 7s LCD (Local Coverage Determination, describes guidelines to be used by National Government Services [NGS] in reviewing hospice claims and by hospice providers to determine eligibility of beneficiaries for hospice benefits) Hospice Eligibility Determination form for Dementia due to Alzheimers, dated 1/29/2024, indicated Patient 7 was eligible per LCD guidelines. The LCD form indicated section 1 and at least one of the conditions in section 2 must be met. It was marked "yes" in section 2 that Patient 7 has inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin (Measures the amount of protein made by the liver in the blood, low albumin level indicates malnutrition) less than 2.5. grams per deciliter (gm/dl). During a review of Patient 7's clinical record indicated there was no documented evidence Patient 7 had 10% weight loss during the previous 6 months or with serum albumin level less than 2.5 gm/dl. During a joint home visit, on 3/12/2024 at 4:10 p.m. with the licensed vocational nurse (LVN 2) at Patient 7s residence, Patient 7 was observed sitting on a wheelchair, was awake, alert and oriented x 1 (to person only), accompanied by a family member (FM 1). During an interview on 3/12/23 at 4:22 p.m., FM 1 stated no doctor or nurses told her that Patient 7 had six months or less to live and did not know that hospice care was for those patients with terminal illness. FM 1 further stated Patient 7 was not dying, has not lost weight but has been gaining weight for the past year, and if ever Patient 7 needed medical emergency, she would not hesitate to call 911 (universal emergency number throughout the United States to request emergency assistance). During an interview on 3/14/2024 at 12:50 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated she was not able to find documented evidence Patient 7 had 10% weight loss during the previous 6 months or with serum albumin level less than 2.5 gm/dl. d. During a closed record review of Patient 12s demographics indicated a start of care date of 12/5/2023 with a terminal diagnosis of Alzheimers disease, unspecified and Patient 12 was discharged on 1/03/2024 because he declined further services. During a review of Patient 12's clinical record indicated that there was no initial comprehensive assessment that was conducted. During a review of Patient 12's "Physician Certification for Hospice Benefit", for the 1st benefit period from 12/5/2023 to 3/3/2024, the Medical Director indicated Patient 12 has a life expectancy of six months or less if the terminal illness ran its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. The ";RN Assessment Narrative" section and the "Certifying Physician Summary" section was blank. The CTI was not signed by the Medical Director. During a review of Patient 12s LCD Hospice Eligibility Determination form indicated Patient 12 does not qualify per LCD guidelines. During an interview on 3/14/2024 at 12:50 p.m. with the Director of Patient Care Services, the DPCS stated she was not employed by the agency when Patient 12 was admitted so she does not know why there was no documented evidence assessment was conducted for Patient 12. During a review of the agencys policy and procedure titled "Admission Criteria and Process", revised November 2022, indicated the agency will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Constant Hospice Care, Inc will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. During a review of the agencys policy and procedure titled ";Certification of Terminal Illness", revised November 2022, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, physician member of the interdisciplinary team and/or the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. a. A review of Patient 1's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated the HA admitted Patient 1 on 11/1/2023, with a diagnosis of hypertensive heart disease (a heart problems that occur because of high blood pressure that is present over a long time) with heart failure (the heart cannot pump enough blood to meet the body's needs). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 11/1/23 to 1/29/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a joint home visit on 3/12/2024, at 1:45 p.m., with LVN 1, Patient 1 was observed walking in steady gait without using an assistive device. During an interview on 3/12/24, at 2 p.m., when asked if she was informed about the purpose of the hospice care services, she stated had no idea what hospice services was about. She also stated the agency would send a nurse to come visit every week to take her vital signs but the visiting nurse came and visited only once during the initial (first) visit. Patient 1 also stated that the agency offered to provide free medical supplies such as lotions, incontinent pads and shampoo upon patient admission to their hospice service. She further stated that she was not sick and not be dying in six months, and that Patient 1called the hospice agency to render their services. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 11/8/2023, with a terminal diagnosis of heart disease ( heart condition that include diseased vessels, structural problems, and blood clots). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 11/8/23 to 2/6/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. On 3/12/2024, at 12 p.m., a joint home visit was conducted at Patient 2's residence. Patient 2 was observed walking with a steady gait without the use of an assistive device. On 3/12/2024, at 12:30 p.m., during an interview with Patient 2, when she was asked if the hospice agency informed the patient and family members about the purpose of the hospice care services, she stated the hospice service will provide a nurse to visit every week to take her blood pressure and provide her with her prescribed medications. She further stated that she was not sick and not be dying in six months, and that her friend referred het to the hospice agency. On 3/15/2024, at 12 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated in order for a new patient to be admitted to their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital from where the patient gets discharged. During a telephone interview on 3/15/2024 at 2 p.m. with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient's 1 and 2 , 7 and 12, and have not spoken and/or discussed Patient's 1,2,7 and 12's medical history with them. Physician 1 stated she determined patient was eligible for hospice care through his 20 years of experience as well as training in the medical school, reviewing patients previous hospital records and discharge planning, and following CMS (The Centers for Medicare & Medicaid Services, is a federal agency within the United States Department of Health and Human Services that administers the Medicare program) and Medicare guidelines in admitting patients in hospice service.

Based on observation, interview and record review, the hospice agency (HA) failed to maintain an accurate, current medication profile for three of 13 sampled patients (Patient 1, Patient 2, and Patient 7). This failure has the potential in placing the patient at risk for medication errors and adverse drug reactions. --- Findings: c. During a review of Patient 7s demographics ((identifying information such as patients name, date of birth and address, along with insurance information) indicated a start of care (SOC) date of 11/1/2023 with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with early onset. During a review of Patient 7's Plan of Care (POC) Summary form indicated an order, dated 11/1/2023, for the licensed vocational nurse (LVN) frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to do an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. Spiritual counselor (SC), social worker (MSW), and hospice aide (CHHA) services were offered but declined. During a joint home visit, on 3/12/2024 at 4:10 p.m. with the licensed vocational nurse (LVN 2) at Patient 7s residence, Patient 7 was observed sitting on a wheelchair, was awake, alert and oriented x 1 (to person only), accompanied by a family member (FM 1). On 3/12/2024, at 4:30 p.m., during a review of Patient 7s current medications with FM 1, the following medications could not be found: 1. Morphine sulfate 100 milligram (mg)/5 milliliter (ml) 0.25 solution oral every 4 hours as needed for moderate to severe pain, 2. Norco 5mg-325mg 1 tablet oral every 6 hours as needed for moderate pain, 3. Meloxicam 7.5 mg 1 tablet oral once a day for pain. However, the patients current medication profile provided by the HA indicated Patient 7 was currently taking these medications. During a concurrent interview with FM 1, she stated Patient 7 was not complaining of pain and the physician stopped prescribing these medications for several months. During an interview on 3/14/2024 at 12:50 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated hospice nursing staff need to review patients current medication on every visit and update the medication profile in the patients clinical record immediately. During a review of the hospice agencys policy and procedure titled, ";Medication Profile", revised November 2022, indicated patients receiving medications administered by the hospice will have a current, accurate medication profile in the clinical record. Medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications. a. A review of Patient 1's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated the HA admitted Patient 1 on 11/1/2023, with a diagnosis of hypertensive heart disease (a heart problems that occur because of high blood pressure that is present over a long time) with heart failure (the heart cannot pump enough blood to meet the body's needs). A review of Patient 1's Physician's order dated 2/7/2024, indicated to administer Basaglar 30 units insulin subcutaneous at bedtime. During a joint home visit on 3/12/2024, at 1:45 p.m., with LVN 1, Patient 1 was observed walking in steady gait without using an assistive device. During a review and observation of Patient 1's medications at home, an unopened box of Basaglar insulin (4 kwikpens, a disposable, single-patient-use prefilled insulin pen) inside the box was observed at Patient 1s home, with a label to administer 30 units at bedtime and filled date of 2/7/2024. During an interview on 3/12/24, at 2 p.m., with Patient 1, Patient 1 stated that the visiting nurse came and visited only once during the initial (first) visit. Patient 1 stated that no one from the agency came to check her medications and her Basaglar insulin kwikpens. Patient 1 stated she was not taking the Basaglar insulin because she could barely see the small number written on the insulin kwikpen. Patient 1 stated she needed her prescription glasses to see clearly but she lost it. Patient 1 stated she checked her BS reading in the morning, and her BS reading was 457 mg/dl. During an observation on 3/12/2024, at 2:15 p.m., of Patient 1, Patient 1 was observed checking BS reading using the glucometer and BS reading was 440 mg/dl. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 11/8/2023, with a terminal diagnosis of heart disease ( heart condition that include diseased vessels, structural problems, and blood clots). A review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 1/17/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to two visits per week, registered nurse (RN) to conduct initial evaluation within five days of admission then every recertification. A review of Patient 2's Physician's order dated 11/8/2023, indicated to administer Clonidine 0.1 mg (milligrams) one tab every 6 hours as needed for high blood pressure. On 3/12/2024, at 12 p.m., a joint home visit was conducted at Patient 2's residence. Patient 2 was observed walking with a steady gait without the use of an assistive device. During a review and observation of Patient 2's medications at home, there was a bottle of Clonidine with a label to administer 0.1 mg (milligrams) one tab daily. On 3/12/2024, at 12:30 p.m., during an interview with Patient 2, she stated she does not take the Clonidine medication at all. During an interview and concurrent record review on 3/14/2024, at 1:00 p.m., with the Director of Patient Care Services (DPCS), of Patient 1 and 2s medical record (in general), the DPCS stated the visiting nurse should have checked all the patient's prescribed medications during visits.

Based on interview and record review, the hospice agency (HA) failed to provide initial bereavement assessment for seven of 13 sampled patients (Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). This deficient practice had the potential to impact a family members' abilities to cope with the patients' death. --- Findings: a. During a review of Patient 7s demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated a start of care (SOC) date of 11/1/2023, with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with early onset. During a review of Patient 7's Plan of Care (POC) Summary form indicated an order, dated 11/1/2023, for the licensed vocational nurse (LVN) frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to do an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. Spiritual counselor (SC), social worker (MSW), and hospice aide (CHHA) services were offered but declined. During a review of Patient 7's clinical record indicated that there was no initial bereavement assessment conducted. b. During a review of Patient 8s demographics indicated a start of care date of 2/21/2024, with a terminal diagnosis of Alzheimers disease, unspecified. During a review of Patient 8's POC Summary form indicated an order, dated 2/21/2024, for the skilled nurse (SN) frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, the registered nurse (RN) to do an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management, MSW to conduct an initial assessment within 5 days from SOC, and the CHHA visit will start on 3/11/2024 as requested by patients caregiver. Spiritual counselor service was offered but declined. During a review of Patient 8's clinical record indicated that there was no initial bereavement assessment conducted. c. During a review of Patient 9s demographics indicated a start of care date of 1/29/2024, with a terminal diagnosis of Alzheimers disease, unspecified. During a review of Patient 9's POC Summary form indicated an order, dated 1/29/2024, for the LVN frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, the registered nurse (RN) to do an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management, and MSW to conduct an initial assessment on the 14th day after SOC as per patient request. Spiritual counselor and CHHA services were offered but declined. During a review of Patient 9's clinical record indicated that there was no initial bereavement assessment conducted. d. During a closed record review of Patient 10s demographics indicated a start of care date of 11/18/2023, with a terminal diagnosis of cerebral infarction (also called a stroke, it occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to embolism (a blood clot that blocks the blood supply to an organ in the body) of right middle cerebral artery (an artery that supplies blood to the brain). During a review of Patient 10's POC Summary form indicated an order, dated 11/18/2023, for the skilled nurse frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to conduct an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. SC, MSW, and CHHA services were offered but declined. During a review of Patient 10's clinical record indicated that there was no initial bereavement assessment conducted. e. During a closed record review of Patient 11s demographics indicated a start of care date of 11/1/2023 with a terminal diagnosis of myocarcardial infarction (or heart attack, a blockage of blood flow to the heart muscle) type 2. During a review of Patient 11's POC Summary form indicated an order, dated 11/1/2023, for the skilled nurse frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to conduct an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. SC, MSW, and CHHA services were offered but declined. During a review of Patient 11's clinical record indicated that there was no initial bereavement assessment conducted. f. During a closed record review of Patient 12s demographics indicated a start of care date of 12/5/2023 with a terminal diagnosis of Alzheimers disease, unspecified. During a review of Patient 12s POC Summary form indicated no frequency of visits was ordered for all IDG ( or Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary that includes a RN, SN, MSW and SC) members. During a review of Patient 12's clinical record indicated that there was no initial bereavement assessment conducted. g. During a closed record review of Patient 13s demographics indicated a start of care date of 11/1/2023 with a terminal diagnosis of malignant neoplasm (a cancerous tumor) of unspecified site of unspecified female breast. During a review of Patient 13s POC Summary form indicated no frequency of visits was ordered for all IDG members. During a review of Patient 13's clinical record indicated that there was no initial bereavement assessment conducted. During an interview on 3/14/2024 at 12:50 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated that an initial bereavement assessment should be conducted on admission and then documented on the patients clinical record. The DPCS further stated that Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13 did not have an initial bereavement assessment conducted on admission. During a review of the agency's policy and procedure titled "Bereavement Assessment," revised November 2022, indicated that on admission, the social worker, chaplain or hospice registered nurse will complete a bereavement risk assessment that will be given to the bereavement coordinator. All bereavement documentation will be submitted for filing in the patients permanent clinical record.

Based on observation, interview, and record review, the Hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live), failed to meet the Condition of Participation (refer to the requirements that healthcare organizations must meet to participate in federal healthcare programs) for ) 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), Care Planning, and Coordination of Services was met as follows: --- 1. The hospice agency failed to ensure the IDG meetings were held by all the members of interdisciplinary group to discuss the patients comprehensive and ongoing assessments and care planning process for two out of 13 sampled patients (Patient 8 and Patient 9). (Refer to L541) 3. The hospice agency failed to ensure the plan of care includes the frequency of home visit of hospice staff to render hospice care and services for two out of 13 sampled patients (Patient 12 and Patient 13). (Refer to L547) 4. The hospice agency failed to ensure the patients' written plan of care was reviewed and revised by the interdisciplinary group (IDG) no less frequently than every 15 days for nine of 13 sampled patients (Patient 1, Patient 2, Patient 3, Patient 7, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). (Refer to L552) 5. The hospice agency nursing staff failed to coordinate care and ensure the IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) was notified and the notification was documented when ordered home visit service was missed for two out of 13 sampled patients (Patient 8 and Patient 10). (Refer to L554) 6. The hospice agency failed to ensure home visit was conducted in accordance with the plan of care for three of 13 sampled patients (Patient 1, Patient 8, and Patient 10). (Refer to L555) 1. The Hospice agency (HA) failed to develop a plan of care for diabetic management for one out of 13 patients (Patient 1) that resulted to: a. The HA failed to ensure Patient 1 was receiving Basaglar (long-acting basal insulin used to control high blood sugar) 30 units subcutaneous (the insertion of medications beneath the skin by injection) at bedtime as ordered by the primary physician on 2/7/2024. b. The Licensed Vocational Nurse 1 (LVN 1) did not perform medication reconciliation (a process of comparing medications) and did not provide teaching to Patient 1 on how to self-administer Basaglar 30 units insulin and how to check blood sugar (BS) readings using a glucometer during home visit. These deficient practices resulted in Patient 1 not receiving the Basaglar 30 units at bedtime from 2/7/2024 to 3/13/2024. Patient l's blood sugar result on 3/12/2024 was 457 milligrams per deciliter (mg/dl, unit of measurement) in the morning and 440 mg/dI at 2 pm., and placed Patient 1 at risk for hyperglycemia (high blood sugar levels) that could lead to nausea and vomiting, shortness of breath, difficulty concentrating, confusion (lack of understanding), and unresponsiveness (loss of consciousness [the state of being aware]). (Refer to L545). The cumulative effect of these systemic practices resulted in the failure of the HHA to deliver statutorily mandated (written law) compliance with Federal Regulations for IDG, Care Planning, and Coordination of Services to ensure provision of quality care and services to patients assessed to receive home health services.

Based on interview and record review, the hospice agency failed to ensure the IDG meetings were held by all the members of interdisciplinary group to discuss the patients comprehensive and ongoing assessments and care planning process for two out of 13 sampled patients (Patient 8 and Patient 9). This deficient practice had the potential to missed and not identified Patient 8 and Patient 9 progress or decline by the IDG, interventions not be implemented, and patient care goals not be achieved. --- Findings: a. During a review of Patient 8s demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated a start of care (SOC) date of 2/21/2024, with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified. During a review of Patient 8's Plan of Care (POC)/IDG form, dated 3/2/2024, indicated the frequency of visits of skilled nurse (SN) to 1 visit per week plus 1 visit as needed for pain, comfort and symptom management, hospice aide (HA) to two visit per week, and the MSW (Social worker) to perform an initial assessment within 5 days from SOC. Spiritual counselor (SC) service was declined. The POC/IDG form has no signatures from the Medical Director, Registered nurse, and the MSW that indicated they attended the IDG meeting. b. During a review of Patient 9s demographics indicated a start of care date of 1/29/2024, with a terminal diagnosis of Alzheimers disease, unspecified. During a review of Patient 9's POC/IDG form, dated 3/2/2024, indicated the frequency of visits of skilled nurse to 1 visit per week plus 1 visit as needed for pain, comfort and symptom management, and the MSW to visit once a month plus 1 prn visit. SC and hospice aide services were declined. The POC/IDG form has no signatures from the Medical Director, RN and the MSW that indicated they attended the IDG meeting. During a concurrent interview and record review of Patient 9's POC/IDG form,, on 3/14/2024 at 12:50 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the agency holds IDG meetings every two weeks. The DPCS stated the IDG members attending the meetings include the RN, LVN, MSW, MD, and SC. The DPCS stated the IDG members were expected to sign the IDG Plan of Care after the meeting because their signature means they attended the meeting. The DPCS was not able to provide documented evidence all the IDG members had participated in the IDG meetings for Patient 8 and Patient 9 on the above days. During a review of the agency's policy and procedure titled, "Interdisciplinary Group Meeting," revised November 2022, 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. Each patients 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 patients condition requires. Members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor/Nursing Supervisor.

Based on observation, interview, and record review, the Hospice agency (HA, providing care to terminally ill patients who have six months or less to live) failed to ensure to develop a plan of care for diabetic (a group of diseases that result in too much sugar in the blood (high blood glucose) management for eight of 13 sampled patients (Patients 1, 2, 3, 6, 7, 10 and 12) by failing to: 1.Ensure Patient 1 received Basaglar (a long-acting insulin used to control high blood sugar) 30 units subcutaneous (the insertion of medications beneath the skin by injection) at bedtime, as ordered by the primary physician on 2/7/2024. 2.Ensure LVN 1 conduct medication reconciliation (a process of comparing medications), provide teaching to Patient 1 on the administration of Basaglar 30 units insulin and how to check blood sugar (BS) readings using a glucometer during home visit. These deficient practices resulted in Patient 1 not receiving the Basaglar 30 units at bedtime from 2/7/2024 to 3/13/2024. Patient 1's BS reading on 3/12/2024 in the morning was 457 milligrams per deciliter (mg/dl, unit of measurement) and Patient 1's BS reading on 3/12/2024 at 2 p.m., was 440 mg/dl, and could place Patient 1 at risk for hyperglycemia (high blood sugar levels, headache, blurred vision, confusion (lack of understanding), and unresponsiveness (loss of consciousness [the state of being aware]), or hypoglycemia (low blood sugar levels, confusion, and unresponsiveness. On 3/13/2024, at 2:44 p.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called in the presence of the agencys Administrator Designee (ADMD) and the Office Manager (OM) related to the agencys failure to develop Patient 1's plan of care for diabetic management. The hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure Patient 1 received Basaglar (a long-acting insulin used to control high blood sugar) 30 units subcutaneous (the insertion of medications beneath the skin by injection) at bedtime as ordered by the primary physician on 2/7/2024. The Licensed Vocational Nurse 1 (LVN 1) failed to conduct medication reconciliation (a process of comparing medications) for Patient 1, provide teaching to Patient 1 on the administration Basaglar 30 units subcutaneous at bedtime, and to check blood sugar (BS) readings using a glucometer (a device for measuring the concentration of glucose [sugar] in the blood) during visits.Patient 1 did not receive the Basaglar 30 units at bedtime from 2/7/2024 to 3/13/2024 as ordered by the primary physician. Patient 1s BS reading on 3/12/2024 in the morning was 457 milligrams per deciliter (mg/dl, unit of measurement, [normal fasting blood glucose level is between 70 and 100 mg/dL]) and Patient 1s BS reading on 3/12/2024 at 2 p.m., was 440 mg/dl. On 3/15/2024, at 10:12 a.m., the HA submitted an IJ removal plan (the facilitys plan of action to correct the deficient practices) by email, the IJ removal plan reviewed by survey team, and on 3/15/2024, at 4:08 p.m., the survey team notified the ADMD that the IJ removal plan was not accepted. --- b. During a review of Patient 7s demographics indicated a start of care (SOC) date of 11/1/2023 with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with early onset. During a review of Patient 7's Comprehensive Nursing 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), dated 11/01/2023, indicated Patient 7 was awake, alert, oriented x 1 (to person only), had regular pulse (heart rate), had normal respirations (breathing) with episodes of shortness of breath (SOB), and was dependent on walker or cane. During a review of Patient 7s clinical record indicated there was no plan of care developed and completed that includes specific goals and interventions regarding Patient 7 care needs. c. During a closed record review of Patient 10s demographics indicated a start of care date of 11/18/2023, with a terminal diagnosis of cerebral infarction (also called a stroke, it occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to embolism (a blood clot that blocks the blood supply to an organ in the body) of right middle cerebral artery (an artery that supplies blood to the brain). During a review of Patient 10's Comprehensive Nursing Assessment, dated 11/18/2023, indicated Patient 10 was awake, alert, oriented x 2 (to place and person), had regular pulse, had mild SOB at rest, had dull pain on left shoulder, and was bedbound. During a review of Patient 10s clinical record indicated there was no plan of care developed and completed that includes specific goals and interventions regarding Patient 10 care needs. d. During a closed record review of Patient 11s demographics indicated a start of care date of 11/1/2023 with a terminal diagnosis of myocarcardial infarction (or heart attack, a blockage of blood flow to the heart muscle) type 2. During a review of Patient 11's Comprehensive Nursing Assessment, dated 11/1/2023, indicated Patient 11 was awake, alert, oriented x 3 (to time, place, and person), had regular pulse, poor endurance, had episodes of moderate SOB at exertion even at rest, and was dependent on walker or cane. During a review of Patient 11s clinical record indicated there was no plan of care developed and completed that includes specific goals and interventions regarding Patient 11 care needs. e. During a closed record review of Patient 12s demographics indicated a start of care date of 12/5/2023 with a terminal diagnosis of Alzheimers disease, unspecified. During a review of Patient 12s clinical record indicated that there was no documented evidence the initial comprehensive assessment was conducted, and there was no plan of care developed and completed that includes specific goals and interventions regarding Patient 12 care needs. During a concurrent interview and record review, on 3/14/2024 at 12:50 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated patients POC should be developed on admission based on the comprehensive assessment. DPCS confirmed the plan of care with measurable objectives, timeframe, and interventions were not developed for Patient 7, Patient 10, Patient 11, and Patient 12). During a review of the agency's policy and procedure titled, "The Plan of Care", revised November 2022, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen days. This plan will focus on identified problems, goals, and interventions. A review of Patient 1's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated the HA admitted Patient 1 on 11/1/2023, with a diagnosis of hypertensive heart disease (a heart problems that occur because of high blood pressure that is present over a long time) with heart failure (the heart cannot pump enough blood to meet the body's needs). A review of Patient 1's Physician's order dated 2/7/2024, indicated to administer Basaglar 30 units insulin subcutaneous at bedtime. During a joint home visit on 3/12/2024, at 1:45 p.m., with LVN 1, Patient 1 was observed walking in steady gait without using an assistive device. During a review and observation of Patient 1's medications at home, an unopened box of Basaglar insulin (4 kwikpens, a disposable, single-patient-use prefilled insulin pen) inside the box was observed at Patient 1s home, with a label to administer 30 units at bedtime and filled date of 2/7/2024. During an interview on 3/12/24, at 2 p.m., with Patient 1, Patient 1 stated that the visiting nurse came and visited only once during the initial (first) visit. Patient 1 stated that no one from the agency came to check her medications and her Basaglar insulin kwikpens. Patient 1 stated she was not taking the Basaglar insulin because she could barely see the small number written on the insulin kwikpen. Patient 1 stated she needed her prescription glasses to see clearly but she lost it. Patient 1 stated she checked her BS reading in the morning, and her BS reading was 457 mg/dl. During an observation on 3/12/2024, at 2:15 p.m., of Patient 1, Patient 1 was observed checking BS reading using the glucometer and BS reading was 440 mg/dl. During an interview and concurrent record review on 3/14/2024, at 1:00 p.m., with the Director of Patient Care Services (DPCS), of Patient 1s medical record (in general), the DPCS stated that there was no plan of care developed for Patient 1 for diabetic management. A review of the agency's undated policy and procedure titled, "Plan of Care", indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on interview and record review, the HA failed to ensure the plan of care (POC) includes the frequency of home visit of hospice staff to render hospice care and services for two out of 13 sampled patients (Patient 12 and Patient 13). This deficient practice placed the patients at risk of not being cared for by the agency and has the potential to negatively affect the patient's quality of life. --- Findings: a. During a closed record review of Patient 12s demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated a start of care date of 12/5/2023 with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified. During a review of Patient 12s POC Summary form indicated no frequency of visits was ordered for all IDG (or Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary that includes a RN, SN, MSW and SC) members. b. During a closed record review of Patient 13s demographics indicated a start of care date of 11/1/2023 with a terminal diagnosis of malignant neoplasm (a cancerous tumor) of unspecified site of unspecified female breast. During a review of Patient 13s POC Summary form, the POC Summary form had no frequency of visits was ordered for all IDG members. During a concurrent interview and record review, on 3/14/2024 at 12:50 p.m. with the Director of Patient Care Services (DPCS), the DPCS could not provide the documented evidence that the frequency of visits of each hospice discipline/services was included in the POC for Patient 12 and Patient 13. The DPCS stated the frequency of visit of IDG members should have been included in the POC. During a review of the agency's policy and procedure titled "The Plan of Care", revised in November 2022, indicated the plan of care will identify the patient's needs and services to meet those needs, including the management of pain, and discomfort and symptom relief. It must state, in detail, the scope and frequency of services needed to meet the patients and family/caregivers needs.

Based on observation, interview, and record review, the hospice agency failed to ensure the IDG group (interdisciplinary group, a team responsible for the holistic care of the hospice beneficiary) reviewed and revised the patients' written plan of care (POC) no less frequently than every 15 days for ten of 13 sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). This deficient practice had a potential to result in lacking continuous assessment and care planning that meet patients' needs. --- e. During a review of Patient 7s demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated a start of care (SOC) date of 11/1/2023, with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with early onset. During a review of Patient 7's Plan of Care Summary form indicated an order, dated 11/1/2023, for the licensed vocational nurse (LVN) frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to do an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. Spiritual counselor (SC), social worker (MSW), and hospice aide (CHHA) services were offered but declined. During a review of Patient 7's clinical record indicated there was no documented evidence the POC/IDG meeting was conducted since the start of care. f. During a review of Patient 9s demographics indicated a start of care date of 1/29/2024, with a terminal diagnosis of Alzheimers disease, unspecified. During a review of Patient 9's POC Summary form indicated an order, dated 1/29/2024, for the LVN frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, the registered nurse (RN) to do an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management, and MSW to conduct an initial assessment on the 14th day after SOC as per patient request. Spiritual counselor and CHHA services were offered but declined. During a review of Patient 9's clinical record indicated there was no documented evidence the POC/IDG meeting was conducted for the month of February 2024 g. During a closed record review of Patient 10s demographics indicated a start of care date of 11/18/2023, with a terminal diagnosis of cerebral infarction (also called a stroke, it occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to embolism (a blood clot that blocks the blood supply to an organ in the body) of right middle cerebral artery (an artery that supplies blood to the brain). During a review of Patient 10's POC Summary form indicated an order, dated 11/18/2023, for the skilled nurse frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to conduct an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. SC, MSW, and CHHA services were offered but declined. During a review of Patient 10's clinical record indicated there was no documented evidence the POC/IDG meeting was conducted since the start of care. h. During a closed record review of Patient 11s demographics indicated a start of care date of 11/1/2023 with a terminal diagnosis of myocarcardial infarction (or heart attack, a blockage of blood flow to the heart muscle) type 2. During a review of Patient 11's POC Summary form indicated an order, dated 11/1/2023, for the skilled nurse frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to conduct an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. SC, MSW, and CHHA services were offered but declined. During a review of Patient 11's clinical record indicated there was no documented evidence the POC/IDG meeting was conducted since the start of care. i. During a closed record review of Patient 12s demographics indicated a start of care date of 12/5/2023 with a terminal diagnosis of Alzheimers disease, unspecified. During a review of Patient 12s POC Summary form indicated no frequency of visits was ordered for all IDG (or Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary that includes a RN, SN, MSW and SC) members. During a review of Patient 12's clinical record indicated there was no documented evidence the POC/IDG meeting was conducted since the start of care. j. During a closed record review of Patient 13s demographics indicated a start of care date of 11/1/2023 with a terminal diagnosis of malignant neoplasm (a cancerous tumor) of unspecified site of unspecified female breast. During a review of Patient 13s POC Summary form indicated no frequency of visits was ordered for all IDG members. During a review of Patient 13's clinical record indicated there was no documented evidence the POC/IDG meeting was conducted since the start of care. During a review of the agency's policy and procedure titled, "Interdisciplinary Group Meeting," revised in November 2022, indicated 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. a. A review of Patient 1's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated the HA admitted Patient 1 on 11/1/2023, with a diagnosis of hypertensive heart disease (a heart problems that occur because of high blood pressure that is present over a long time) with heart failure (the heart cannot pump enough blood to meet the body's needs). During a joint home visit on 3/12/2024, at 1:45 p.m., with LVN 1, Patient 1 was observed walking in steady gait without using an assistive device. During a review and observation of Patient 1's medications at home, an unopened box of Basaglar insulin (4 kwikpens, a disposable, single-patient-use prefilled insulin pen) inside the box was observed at Patient 1s home, with a label to administer 30 units at bedtime and filled date of 2/7/2024. During an interview on 3/12/24, at 2 p.m., with Patient 1, Patient 1 stated that the visiting nurse came and visited only once during the initial (first) visit. Patient 1 stated that no one from the agency came to check her medications and her Basaglar insulin kwikpens. Patient 1 stated she was not taking the Basaglar insulin because she could barely see the small number written on the insulin kwikpen. Patient 1 stated she needed her prescription glasses to see clearly but she lost it. Patient 1 stated she checked her BS reading in the morning, and her BS reading was 457 mg/dl. A review of Patient 1's IDG (interdisciplinary group)/POC (plan of care) Review of Comprehensive Assessment, indicated there was no IDG meeting that took place since the SOC (start of care) of 11/1/2023. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 11/8/2023, with a terminal diagnosis of heart disease ( heart condition that include diseased vessels, structural problems, and blood clots). On 3/12/2024, at 12 p.m., a joint home visit was conducted at Patient 2's residence. Patient 2 was observed walking with a steady gait without the use of an assistive device. During a review and observation of Patient 2's medications at home, there was a bottle of Clonidine with a label to administer 0.1 mg (milligrams) one tab daily. On 3/12/2024, at 12:30 p.m., during an interview with Patient 2, she stated she does not take the Clonidine medication at all. She further stated the visiting nurse does not check her actual medications during their visits. A review of Patient 2's IDG (interdisciplinary group)/POC (plan of care) Review of Comprehensive Assessment, indicated there was no IDG meeting held for the month of February and March 2024. c. A review of Patient 3s admission record indicated a start of care (SOC) date of 11/9/2023, with a terminal diagnosis of cerebral infarction (unspecified occlusion or stenosis of other cerebral arteries). A review of Patient 3's IDG (interdisciplinary group)/POC (plan of care) Review of Comprehensive Assessment, indicated there was no IDG meeting that took place since the SOC (start of care) of 11/9/2023. d. A review of Patient 6s admission record indicated a start of care (SOC) date of 11/1/2023, with a terminal diagnosis of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors). A review of Patient 6's IDG (interdisciplinary group)/POC (plan of care) Review of Comprehensive Assessment, indicated there was no IDG meeting that took place since the SOC (start of care) of 11/1/2023. During a concurrent interview and record review on 3/15/24, at 12 p.m. with the DPCS, she stated she was a newly hire and agreed there was no IDG meeting held. She further stated it was important to have the IDG meetings, so the hospice agency will know what is going on with the patient and to update the patient's plan of care as needed.

Based on interview and record review, the hospice agency nursing staff failed to coordinate care and ensure the IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) were notified and the notification were documented when ordered home visit service was missed for two out of 13 sampled patients (Patient 8 and Patient 10). This failure had the potential to result in patients end of life care needs not being met. --- Findings: a. During a review of Patient 8s demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated a start of care (SOC) date of 2/21/2024, with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified. During a review of Patient 8's Plan of Care (POC) Summary form indicated an order, dated 2/21/2024, for the skilled nurse (SN) frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, the registered nurse (RN) to do an initial evaluation, then every 30 days for licensed vocational nurse (LVN) supervisory visit and scheduled recertification for ongoing assessment and comfort management, MSW (Social worker) to conduct an initial assessment within 5 days from SOC, and the CHHA (hospice aide) visit will start on 3/11/2024 as requested by patients caregiver. Spiritual counselor (SC) service was offered but declined. During a review of Patient 8s history of skilled nursing visit notes for the month of February 2024 and March 2024, indicated there was no SN visit conducted since the SOC. During a telephone interview, on 3/13/2024 at 12:56 p.m., with Patient 8s family member (FM 1), FM 1 stated the hospice agency nurse only visited Patient 8 once during admission to hospice care and have not come back after that. During a further review of Patient 8s clinical record indicated there was no documented evidence that the agencys nursing staff had notified or communicated with the IDG about the missed visit in accordance with the agencys policy and procedure. b. During a closed record review of Patient 10s demographics indicated a start of care date of 11/18/2023, with a terminal diagnosis of cerebral infarction (also called a stroke, it occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to embolism (a blood clot that blocks the blood supply to an organ in the body) of right middle cerebral artery (an artery that supplies blood to the brain). During a review of Patient 10's POC Summary form indicated an order, dated 11/18/2023, for the skilled nurse frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to conduct an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. SC, MSW, and CHHA services were offered but declined. During a review of Patient 10s history of skilled nursing visit notes indicated patient was not visited for about 1 month and a half from 11/25/2023 to 1/5/2024. During a further review of Patient 10s clinical record indicated there was no documented evidence that the agencys nursing staff had notified or communicated with the IDG about the missed visit in accordance with the agencys policy and procedure. During a concurrent interview and record review, on 3/14/2024 at 12:50 p.m. with the Director of Patient Care Services (DPCS), the DPCS acknowledged the findings and stated patient care visit should be provided to patients in accordance with the plan of care. The DPCS stated for any missed visits, IDG should be notified promptly by the field nurses and notification should be documented in the patients records per the agencys policies. During a review of the agencys policy and procedure titled, ";Missed Visits", revised November 2022, indicated missed visits will be communicated to the Interdisciplinary Group at the IDG meeting. A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. If a visit is missed and not rescheduled, the clinician will notify the IDG and clinical supervisor of the missed visit and reason for missed visit and will document in the patients clinical record. Documentation of all communications will be included in the clinical record on a communication note, interdisciplinary group meeting form, and/or clinical note. Documentation will include the date and time of the communication, individuals involved with the communication, information discussed, and the outcome of the communication.

Based on interview and record review, the HA failed to ensure home visit was conducted according to the plan of care (POC) for two of 13 sampled patients (Patients 8, and 10). This deficient practice had the potential to negatively affect the patients' physical comfort, psychosocial well-being, and not receiving the needed and necessary services timely. --- Findings: a. During a review of Patient 8s demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated a start of care (SOC) date of 2/21/2024, with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified. During a review of Patient 8's Plan of Care (POC) Summary form indicated an order, dated 2/21/2024, for the skilled nurse (SN) frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, the registered nurse (RN) to do an initial evaluation, then every 30 days for licensed vocational nurse (LVN) supervisory visit and scheduled recertification for ongoing assessment and comfort management, MSW (Social worker) to conduct an initial assessment within 5 days from SOC, and the CHHA (hospice aide) visit will start on 3/11/2024 as requested by patients caregiver. Spiritual counselor (SC) service was offered but declined. During a review of Patient 8s history of skilled nursing visit notes for the month of February 2024 and March 2024, indicated there was no SN visit conducted since the SOC. During a telephone interview, on 3/13/2024 at 12:56 p.m., with Patient 8s family member (FM 1), FM 1 stated the hospice agency nurse only visited Patient 8 once during admission to hospice care and have not come back after that. b. During a closed record review of Patient 10s demographics indicated a start of care date of 11/18/2023, with a terminal diagnosis of cerebral infarction (also called a stroke, it occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to embolism (a blood clot that blocks the blood supply to an organ in the body) of right middle cerebral artery (an artery that supplies blood to the brain). During a review of Patient 10's POC Summary form indicated an order, dated 11/18/2023, for the skilled nurse frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, and the registered nurse (RN) to conduct an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. SC, MSW, and CHHA services were offered but declined. During a review of Patient 10s history of skilled nursing visit notes indicated patient was not visited for about 1 month and a half from 11/25/2023 to 1/5/2024. During a concurrent interview and record review, on 3/14/2024 at 12:50 p.m. with the Director of Patient Care Services (DPCS), the DPCS acknowledged the findings and stated patient care visit should be provided to patients in accordance with the plan of care. During a review of the agency's policy and procedure titled, "The Plan of Care", revised November 2022, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Core Services was met as follows: --- 1. The hospice agency failed for the Director of Nursing Services (DPCS) to oversee the overall nursing care and services provided for five out of 13 sampled patients (Patient 1, Patient 7, Patient 10, Patient 11, and Patient 12). (Refer to L591) 2. The hospice agency failed to provide medical social services (services addressing social and emotional concerns related to the patient's illness and care and helping the patient access community) to six of 13 sampled patients (Patient 1, Patient 2, Patient 8, Patient 9, Patient 12, and Patient 13). (Refer to L594) The cumulative effect of these systemic practices resulted in the HA not providing the core services/care as required and had the potential for the patients to not receive appropriate healthcare services that could affect their quality of life.

Based on observation, interview, and record review, the Hospice Agency (HA, an agency that provides special care to terminally ill patients who have six months or less to live) failed for the Director of Nursing Services (DPCS) to oversee the overall nursing care and services provided for five out of 13 sampled patients (Patient 1, Patient 7, Patient 10, Patient 11, and Patient 12), by failing to: 1. Ensure the agencys DPCS provided oversight to develop Patient 1s plan of care for diabetes management. The DPCS failed to ensure Patient 1 received Basaglar (a long-acting insulin used to control high blood sugar) 30 units subcutaneous (the insertion of medications beneath the skin by injection) at bedtime as ordered by the primary physician on 2/7/2024. Patient 1 did not receive the Basaglar 30 units at bedtime from 2/7/2024 to 3/13/2024 as ordered by the primary physician. 2. Ensure there was a full-time DPCS to oversee the completion of comprehensive nursing 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) within 5 days after the election of hospice care and develop the plan of care for Patient 7, Patient 10, Patient 11, and Patient 12. These deficient practices placed Patient 1 at risk to experience serious side effect of hyperglycemia (high blood sugar), headache, blurred vision, confusion, and loss of consciousness, and hypoglycemia (low blood sugar level), confusion (lack of understanding), and unresponsiveness (loss of consciousness [the state of being aware]). The deficient practice is likely to cause delayed care, undetected signs of physical, emotional, and spiritual needs when transitioning to the final stages of the dying process, for Patient 7, Patient 10, Patient 11, and Patient 12. On 3/13/2024, at 2:44 p.m., an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) was called in the presence of the agencys Administrator Designee (ADMD) and the Office Manager (OM) related to HAs failure to ensure there was a full-time DPCS to oversee Patient 1s plan of care was developed and implemented for diabetes management, to ensure Patient 1 received Basaglar (a long-acting insulin used to control high blood sugar) 30 units subcutaneous (the insertion of medications beneath the skin by injection) at bedtime as ordered by the primary physician on 2/7/2024. Patient 1 did not receive the Basaglar 30 units at bedtime from 2/7/2024 to 3/13/2024 as ordered by the primary physician. Patient 1s BS reading on 3/12/2024 in the morning was 457 milligrams per deciliter (mg/dl, unit of measurement, [normal fasting blood glucose level is between 70 and 100 mg/dL]) and Patient 1s BS reading on 3/12/2024 at 2 p.m., was 440 mg/dl. The HA failed to ensure to provide oversight for the completion of comprehensive nursing assessment within 5 days after the election of hospice care and developed the plan of care for Patient 7, Patient 10, Patient 11, and Patient 12. On 3/15/2024, at 10:12 a.m., the HA submitted an IJ removal plan (the facilitys plan of action to correct the deficient practices) by email, the IJ removal plan reviewed by survey team, and on 3/15/2024, at 4:08 p.m., the survey team notified the ADMD that the IJ removal plan was not accepted. On 3/15/2024, at 5 p.m., the survey team completed the survey tasks, and exited with the IJ situation not removed. On 3/20/2024 the agency submitted an acceptable IJ Removal Plan related to HAs failure to ensure there was a full-time DPCS to oversee Patient 1s plan of care was developed and implemented for diabetes management, to ensure Patient 1 received Basaglar 30 units subcutaneous at bedtime as ordered by the primary physician on 2/7/2024. The IJ removal plan included the following; 1.Situation:Hospice failed to ensure the agencys Director of Patient Care Services provided oversight to ensure that the agency developed Patient 1s plan of care to assess and manage Patient 1s diabetesCorrective and Preventative Action Plan:The change of DPCS was submitted to the state on 3/18/24 – please see attached post office verification of mailing.LVN, provided patient caregiver training on 3/18/24 at 10:30 am. The caregiver is competent in blood monitoring, glucometer calibration, and insulin administration. LVN will go back tonight to verify via return demonstration of the caregiver checking blood glucose for evening insulin administration and will re-validate insulin administration competency.On 3/17/2024, the RN reassessed Patient 1. All medications, treatment orders, DME, and supplies were assessed and reconciled with the MD. All medications, supplies, and treatment orders not in current use were discontinued to ensure proper medication compliance from the patient. The RN created a plan of care and ensured care coordination with the visiting LVN.The LVN visited on3/16/2024 (6:30 -7 am and 4:45 – 6:15 pm, patient sleeps early),3/17/2024 (am visit was missed due to the patient being asleep still and at 4:45 to 5:15 pm, patient sleeps early) and3/18/2024 (10:30 am for morning insulin, per patient request not to go too early, also, the caregiver was trained at this time, and PM insulin will be given between 6 pm to 7 pm by the caregiver based on when a patient will go to sleep).On 3/14/2024, the agency hired and appointed a new, qualified, and experienced full time Director of Patient Care Services to ensure all IDT meetings are attended, conducted, and documented, and plans of care are created for all patients.On 3/15/2024, an IDT meeting was held at 8:30 am by all members of IDT, including the doctor, the registered nurse, the chaplain, and the social worker. The IDT meeting was also attended by the newly hired and appointed Director of Patient Care Services. All five patient plans of care were created. On 3/15/2024, all agency staff received in-service training from a nurse consultant working with the organization regarding the importance of care planning, providing patients with an individualized plan of care as approved by the IDT, and updated every two weeks by members of the IDT during IDT meetings. The agency created a clinical record audit sheet to maintain the corrective action plan and prevent future noncompliance. To ensure sustained compliance with this plan of correction, a supervisory RN will complete chart audits every two weeks for three months. 2. Situation:Ensure there is a full-time DPCS to oversee the overall patient care and services which included completion of comprehensive assessments within 5 days after the election of hospice care, and the development of plan of care that reflects patient and family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. For Patient 1, Patient 7, and Patient 11, no plan of care was developed, and the comprehensive assessment was not completed within 5 days after the election of hospice care. For Patient 10, no plan of care was developed, and the initial comprehensive assessment was completed and signed by a Licensed Vocational Nurse (LVN 1). For Patient 12, initial comprehensive assessment was not conducted and there was no plan of care developed.Corrective and Preventative Action Plan:On 3/14/2024, the agency hired and appointed a new, qualified, and experienced full time Director of Patient Care Services to ensure all IDT meetings are attended, conducted, and documented, and plans of care are created for all patients.On 3/15/2024, an IDT meeting was held at 8:30 am by all members of IDT, including the doctor, the registered nurse, the chaplain, and the social worker. The IDT meeting was also attended by the newly hired and appointed Director of Patient Care Services. On 3/15/2024, all agency staff received in-service training from a nurse consultant working with the organization regarding the importance of care planning, providing patients with an individualized plan of care as approved by the IDT, and updated every two weeks by members of the IDT during IDT meetings. Patient 1: The IDT team met on 3/15/2024 and created the patients plan of care.Patient 7: The IDT team met on 3/15/2024 and created the patients plan of carePatient 11 was discharged on 1/26/24 – therefore, the plan of care cannot be updated. However, the team will ensure future compliance with creating a care plan and updating every 14 days during the IDT meeting. Patient 10 was also a discharged patient, will prevent future noncompliance.Patient 12 was also a discharged patient, will prevent future noncompliance.All active patients had an IDT, and the plan of care was corrected.The agency created a clinical record audit sheet to maintain the corrective action plan and prevent future noncompliance. To ensure sustained compliance with this plan of correction, a supervisory RN will complete chart audits every two weeks for three months. The survey team conducted an onsite verification of the implementation of the IJ removal plan on 3/21/2024 and the IJ was removed on 3/21/2024 at 3:55 p.m., in the presence of the new DPCS (DPCS 2), Administrator Designee and the Office Manager. --- Findings: a. A review of Patient 1's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated the HA admitted Patient 1 on 11/1/2023, with a diagnosis of hypertensive heart disease (a heart problems that occur because of high blood pressure that is present over a long time) with heart failure (the heart cannot pump enough blood to meet the body's needs). A review of Patient 1's Physician's order dated 2/7/2024, indicated to administer Basaglar 30 units insulin subcutaneous at bedtime. During a joint home visit on 3/12/2024, at 1:45 p.m., with LVN 1, Patient 1 was observed walking in steady gait without using an assistive device. During a review and observation of Patient 1's medications at home, an unopened box of Basaglar insulin (4 kwikpens, a disposable, single-patient-use prefilled insulin pen) inside the box was observed at Patient 1s home, with a label to administer 30 units at bedtime and filled date of 2/7/2024. During an interview on 3/12/24, at 2 p.m., with Patient 1, Patient 1 stated that the visiting nurse came and visited only once during the initial (first) visit. Patient 1 stated that no one from the agency came to check her medications and her Basaglar insulin kwikpens. Patient 1 stated she was not taking the Basaglar insulin because she could barely see the small number written on the insulin kwikpen. Patient 1 stated she needed her prescription glasses to see clearly but she lost it. Patient 1 stated she checked her BS reading in the morning, and her BS reading was 457 mg/dl. During an observation on 3/12/2024, at 2:15 p.m., of Patient 1, Patient 1 was observed checking BS reading using the glucometer and BS reading was 440 mg/dl. During an interview and concurrent record review on 3/14/2024, at 1:00 p.m., with the Director of Patient Care Services (DPCS), of Patient 1s medical record (in general), the DPCS stated that there was no plan of care developed for Patient 1 for diabetic management. b. During a review of Patient 7s demographics indicated a start of care (SOC) date of 11/1/2023 with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with early onset. During a review of Patient 7's "Physician Certification for Hospice Benefit" (or CTI, physician's certification of the patient being terminally ill to have Medicare hospice benefit) for the 1st benefit period from 11/01/2023 to 1/29/2024, indicated Patient 7's primary terminal diagnoses was Alzheimers disease with early onset. The CTI was not signed by the Medical Director (Physician 1). During a review of Patient 7's Comprehensive Nursing 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), dated 11/01/2023, indicated Patient 7 was awake, alert, oriented x 1 (to person only), had regular pulse (heart rate), had normal respirations (breathing) and clear lung sounds. The assessment was signed by the DPCS on 2/09/2024, or more than three months after the assessment was conducted. During a review of Patient 7s clinical record (in general) indicated there was no plan of care developed and completed that includes specific goals and interventions regarding patient care needs. During a concurrent interview and record review on 3/14/2024 at 12:50 p.m., with the DPCS, Patient 7s initial comprehensive assessment was reviewed. DPCS stated the assessment was conducted by the nurse assigned during the SOC on 11/01/2023, and she reviewed the assessment when she was first hired as the DPCS on the first week of February 2024 and signed the form only on 2/09/2024 to complete Patient 7s comprehensive assessment. DPCS stated Patient 7s comprehensive assessment should have been completed and signed by a registered nurse within 5 days from the start of care of hospice service, and confirmed the plan of care with measurable objectives, timeframe, and interventions were not developed for Patient 7. c. During a closed record review of Patient 10s demographics indicated a start of care date of 11/18/2023 with a terminal diagnosis of cerebral infarction (also called a stroke, it occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to embolism (a blood clot that blocks the blood supply to an organ in the body) of right middle cerebral artery (an artery that supplies blood to the brain). During a review of Patient 10's "Physician Certification for Hospice Benefit" for the 1st benefit period from 11/18/2023 to 2/15/2024, indicated Patient 10's primary terminal diagnoses was cerebral infarction. The CTI was not signed by the Medical Director. During a review of Patient 10's Comprehensive Nursing Assessment, dated 11/18/2023, indicated Patient 10 was awake, alert, oriented x 2 (to place and person), had regular pulse, had normal respirations and was bedbound. The assessment was completed and signed by a licensed vocational nurse (LVN 1), on 2/06/2024, or more than two and a half months after the assessment was conducted. During a review of Patient 10s clinical record indicated there was no plan of care developed and completed that includes specific goals and interventions regarding patient care needs. During a concurrent interview and record review on 3/14/2024 at 12:50 p.m., with the DPCS, Patient 10s initial comprehensive assessment was reviewed. The DPCS stated the comprehensive nursing assessment should be completed and signed by a registered nurse and not by a licensed vocational nurse. DPCS stated Patient 10s comprehensive assessment was not completed within 5 days from the start of care of hospice service and confirmed the plan of care with measurable objectives, timeframe, and interventions were not developed for Patient 10. During a telephone interview on 3/14/2023 at 1:30 p.m., with LVN 1, LVN 1 stated, she signed and completed Patient 10s initial comprehensive assessment. When asked if it was within her scope of practice to sign and complete the comprehensive nursing assessment, LVN 1 stated, ";I get mixed information about it that an LVN can, and others say we cannot. Im fairly new to hospice". When asked why she did not consult with the agencys DPCS or a registered nurse supervisor, LVN 1 stated, ";I dont want to lie to you and make up stuff. I just go to my visit as they scheduled me, but I dont know who was the DPCS or the nurse supervisor during that time around November of last year." d. During a closed record review of Patient 11s demographics indicated a start of care date of 11/1/2023 with a terminal diagnosis of myocardial infarction (or heart attack, a blockage of blood flow to the heart muscle) type 2. During a review of Patient 11's "Physician Certification for Hospice Benefit" for the 1st benefit period from 11/1/2023 to 1/29/2024, indicated Patient 11's primary terminal diagnoses was myocardial infarction type 2. The CTI was not signed by the Medical Director. During a review of Patient 11's Comprehensive Nursing Assessment, dated 11/1/2023, indicated Patient 11 was awake, alert, oriented x 3 (to time, place, and person), had regular pulse, had normal respirations, and had no cardiac-related pain. The assessment was signed and completed by the DPCS on 3/11/2024, or more than four months after the assessment was conducted. During a review of Patient 11s clinical record indicated there was no initial plan of care developed and completed that includes specific goals and interventions regarding patient care needs. During a concurrent interview and record review with the DPCS, on 3/14/2024 at 12:50 p.m., Patient 11s initial comprehensive assessment was reviewed. DPCS stated the assessment was conducted by the nurse assigned during the SOC on 11/01/2023, and that she just recently reviewed the initial nursing assessment and then signed the form to complete Patient 11s comprehensive assessment. DPCS further stated Patient 11s comprehensive assessment should have been completed and signed by a registered nurse within 5 days from the start of care of hospice service, and confirmed the plan of care with measurable objectives, timeframe, and interventions were not developed for Patient 11. e. During a closed record review of Patient 12s demographics indicated a start of care date of 12/5/2023 with a terminal diagnosis of Alzheimers disease, unspecified. During a review of Patient 12's "Physician Certification for Hospice Benefit" for the 1st benefit period from 12/5/2023 to 3/3/2024, indicated Patient 12's primary terminal diagnoses was Alzheimers disease, unspecified. There was no RN assessment narrative and no Physician narrative note on the CTI. The CTI was also not signed by the Medical Director. During a review of Patient 12s clinical record indicated there was no documented evidence the initial comprehensive nursing assessment was conducted, and the plan of care was developed and completed that includes specific goals and interventions regarding patient care needs. During a concurrent interview and record review with the DPCS, on 3/14/2024 at 12:50 p.m., the DPCS was unable to provide documented evidence for Patient 12 that the agency conducted the initial comprehensive assessment, and the plan of care was developed that includes specific goals and interventions regarding patient care needs. The DPCS stated she was hired and started working for the agency last month (February 2024), and was only given 6 hours a week as her work hours for the agency. DPCS further stated she does not have a Designee nor was aware if the agency have another registered nurse supervisor working for them. During a telephone interview with the hospice agencys Owner/Medical Director (Physician 1), on 3/15/2024 at 1:09 p.m., when asked who was the agencys DPCS or RN supervisor when he bought the agency in November 2023 and had their first patient, Physician 1 stated, ";I dont have that information. I dont really know their names." During a review of the agencys policy and procedure titled, ";Hospice Nursing Care", revised November 2022, indicated nursing services will be provided in accordance with the accepted standards of practice by or under the supervision of a registered nurse. The hospice registered nurse performs initial, comprehensive and ongoing comprehensive assessments regarding the impact of the terminal diagnosis on the patients physical, functional, psychosocial, and environmental needs and activities of daily living. The hospice nurse will participate in developing and implementing the plan of care and will report the condition of patient and family/caregiver to the attending physician, hospice Medical Director and interdisciplinary group on a regular basis, as well as changes in the plan of care. During a review of the agencys policy and procedure titled, ";Comprehensive Assessment", revised November 2022, indicated a comprehensive patient assessment will be performed by the hospice IDG no later than 5 calendar days after the election of hospice care in consultation with attending physician. The assessment should determine probable prognosis of six months or less, patient problems and needs related to the terminal illness, patient goals related to the terminal illness, types of services, frequency and duration needed to meet patient care needs, anticipated discharge needs including bereavement and funeral needs, and the need for an alternative level of care. The Clinical Supervisor/Nursing Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. During a review of the agency's policy and procedure titled, "The Plan of Care", revised November 2022, indicated a written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The care provided to the patient must be in accordance with the plan of care. The plan of care will identify the patients needs and services to meet those needs, including the management of pain and discomfort and symptom relief.

Based on observation, interview and record review, the hospice agency failed to provide medical social services (services addressing social and emotional concerns related to the patient's illness and care and helping the patient access community) to six of 13 sampled patients (Patient 1, Patient 2, Patient 8, Patient 9, Patient 12, and Patient 13). This failure had the potential that the available services to support the psychosocial needs were not made available and accessible to the patients and family members under the agency's care. --- c. During a review of Patient 8s demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated a start of care (SOC) date of 2/21/2024, with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), unspecified. During a review of Patient 8's Plan of Care (POC) Summary form indicated an order, dated 2/21/2024, for the skilled nurse (SN) frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, the registered nurse (RN) to do an initial evaluation, then every 30 days for licensed vocational nurse (LVN) supervisory visit and scheduled recertification for ongoing assessment and comfort management, social worker (MSW) to conduct an initial assessment within 5 days from SOC, and the hospice aide (CHHA) visit will start on 3/11/2024 as requested by patients caregiver. Spiritual counselor (SC) service was offered but declined. During a review of Patient 8's clinical record indicated there was no documented evidence a psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family) was completed since the SOC. d. During a review of Patient 9s demographics indicated a start of care date of 1/29/2024, with a terminal diagnosis of Alzheimers disease, unspecified. During a review of Patient 9's POC Summary form indicated an order, dated 1/29/2024, for the LVN frequency of visits to one visit per week and one visit as needed for pain, comfort and symptom management, the registered nurse to do an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management, and MSW to conduct an initial assessment on the 14th day after SOC as per patient request. Spiritual counselor and CHHA services were offered but declined. During a review of Patient 9's clinical record indicated there was no documented evidence a psychosocial assessment was completed since the SOC. e. During a closed record review of Patient 12s demographics indicated a start of care date of 12/5/2023 with a terminal diagnosis of Alzheimers disease, unspecified. During a review of Patient 12s POC Summary form indicated no frequency of visits was ordered for all IDG (or Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary that includes a RN, SN, MSW and SC) members. During a review of Patient 12's clinical record indicated there was no documented evidence a psychosocial assessment was completed since the SOC. f. During a closed record review of Patient 13s demographics indicated a start of care date of 11/1/2023 with a terminal diagnosis of malignant neoplasm (a cancerous tumor) of unspecified site of unspecified female breast. During a review of Patient 13s POC Summary form indicated no frequency of visits was ordered for all IDG members. During a review of Patient 13's clinical record indicated there was no documented evidence a psychosocial assessment was completed since the SOC. During a concurrent interview and record review with the DPCS, on 3/14/2024 at 12:50 p.m., the DPCS stated the agencys social worker just submitted her resignation and agency does not have a social worker currently employed. DPCS stated and acknowledged there was no documented evidence psychosocial assessment was conducted and completed for Patient 1, Patient 2, Patient 8, Patient 9, Patient 12, and Patient 13 since the SOC. During a review of the agencys policy and procedure titled, ";Psychosocial Assessment," revised November 2022, indicated an in-depth psychosocial assessment will be completed by a qualified hospice social worker or hospice registered nurse. The assessment includes but is not limited to coping with and adjusting to the patients terminal illness, making final arrangements, reaction to the terminal illness and subsequent bereavement needs, and social and financial needs. The assessment will be completed and placed in the patients clinical record. a. A review of Patient 1's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated the HA admitted Patient 1 on 11/1/2023, with a diagnosis of hypertensive heart disease (a heart problems that occur because of high blood pressure that is present over a long time) with heart failure (the heart cannot pump enough blood to meet the body's needs). During a joint home visit on 3/12/2024, at 1:45 p.m., with LVN 1, Patient 1 was observed walking in steady gait without using an assistive device. On 3/12/2024, at 2 p.m., during an interview with Patient 1, when asked if a social worker came to visit her, she stated she had no visit from the hospice agency's social worker yet. A review of Patient 1's Initial Comprehensive Nursing Assessment dated 11/1/2023, indicated under the Referral section showed that the box for social worker service was checked and the patient wanted the service. A further Review of Patient 1's clinical record indicated no documented evidence of a social worker notes justifying services was rendered to Patient 1. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 11/8/2023, with a terminal diagnosis of heart disease ( heart condition that include diseased vessels, structural problems, and blood clots). A review of Patient 2's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 1/17/2024, indicated the frequency of visits of licensed vocational nurse (LVN) to two visits per week, registered nurse (RN) to conduct initial evaluation within five days of admission then every recertification. On 3/12/2024, at 12 p.m., a joint home visit was conducted at Patient 2's residence. Patient 2 was observed walking with a steady gait without the use of an assistive device. On 3/12/2024, at 12:45 p.m., during an interview with Patient 2, when asked if a social worker came to visit her, she stated no, she was waiting for a social worker to visit her. A review of Patient 2's Initial Comprehensive Nursing Assessment dated 11/8/2023, indicated under the Referral section showed that the box for social worker service was checked and the patient wanted the service. A further Review of Patient 2's clinical record indicated no documented evidence of a social worker notes justifying services was rendered to Patient 2. On 3/15/2024, at 11:40 a.m., during an interview with the DPCS, she stated she could not find any social worker notes for both Patients 1 and 2 to verify if service was provided.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [is federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [a joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) for Medical Director was met as evidenced by: --- The HA failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (healthcare that focuses on the palliation [specialized medical care for people living with a serious illness] of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for three out of 13 sampled patients (Patient 1, Patient 2, and Patient 12). (Refer to L667). The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory (written rules or law) mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Medical Director and/or physician designee conducted an accurate assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for three out of 13 sampled patients (Patient 1, Patient 2, and Patient 12). This deficient practice resulted in Patient 1, Patient 2, and Patient 12, being admitted for hospice care with no documented evidence of patients written clinical information was being reviewed and evaluated by the Medical Director and/or physician designee to support their diagnoses of terminal illness. --- c. During a closed record review of Patient 12s demographics indicated a start of care date of 12/5/2023 with a terminal diagnosis of Alzheimers disease, unspecified and Patient 12 was discharged on 1/03/2024 because he declined further services. During a review of Patient 12's clinical record indicated that there was no initial comprehensive assessment that was conducted. During a review of Patient 12's "Physician Certification for Hospice Benefit", for the 1st benefit period from 12/5/2023 to 3/3/2024, the Medical Director indicated Patient 12 has a life expectancy of six months or less if the terminal illness ran its normal course. There was no documented evidence the hospice's Medical Director communicated with the patients primary physician to certify Patient 12 had a life expectancy of six months or less if the terminal illness runs its normal course. The ";RN Assessment Narrative" section and the "Certifying Physician Summary" section was blank. The CTI was not signed by the Medical Director. During a review of Patient 12s LCD Hospice Eligibility Determination form indicated Patient 12 does not qualify per LCD guidelines. During an interview on 3/14/2024 at 12:50 p.m. with the Director of Patient Care Services, the DPCS stated she was not employed by the agency when Patient 12 was admitted so she does not know why there was no documented evidence assessment was conducted for Patient 12. During a telephone interview on 3/15/2024 at 1:09 p.m. with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient's 1 and 2 , 7 and 12, and have not spoken and/or discussed Patient's 1,2,7 and 12's medical history with them. When asked how he determine patients were eligible for hospice care, Physician 1 stated, "I presumed they were referred to hospice so I dont question that. So they were eligible because of that referral from the hospital, I dont go over in details on how eligible they are. Of course I checked RN assessment/visit notes, as well as LCD guidelines". a. A review of Patient 1's demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated the HA admitted Patient 1 on 11/1/2023, with a diagnosis of hypertensive heart disease (a heart problems that occur because of high blood pressure that is present over a long time) with heart failure (the heart cannot pump enough blood to meet the body's needs). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 11/1/23 to 1/29/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. During a joint home visit on 3/12/2024, at 1:45 p.m., with LVN 1, Patient 1 was observed walking in steady gait without using an assistive device. During an interview on 3/12/24, at 2 p.m., when asked if she was informed about the purpose of the hospice care services, she stated had no idea what hospice services was about. She also stated the agency would send a nurse to come visit every week to take her vital signs but the visiting nurse came and visited only once during the initial (first) visit. Patient 1 also stated that the agency offered to provide free medical supplies such as lotions, incontinent pads and shampoo upon patient admission to their hospice service. She further stated that she was not sick and not be dying in six months, and that Patient 1called the hospice agency to render their services. b. A review of Patient 2s admission record indicated a start of care (SOC) date of 11/8/2023, with a terminal diagnosis of heart disease ( heart condition that include diseased vessels, structural problems, and blood clots). A review of Patient 2's Physicians Certification for Hospice Benefit, dated 11/8/23 to 2/6/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy (a medical procedure to examine or diagnose the disease) results showing evidence to support the terminal illness diagnosis. On 3/12/2024, at 12 p.m., a joint home visit was conducted at Patient 2's residence. Patient 2 was observed walking with a steady gait without the use of an assistive device. On 3/12/2024, at 12:30 p.m., during an interview with Patient 2, when she was asked if the hospice agency informed the patient and family members about the purpose of the hospice care services, she stated the hospice service will provide a nurse to visit every week to take her blood pressure and provide her with her prescribed medications. She further stated that she was not sick and not be dying in six months, and that her friend referred het to the hospice agency. On 3/15/2024, at 12 p.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated in order for a new patient to be admitted to their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital from where the patient gets discharged. During a telephone interview on 3/15/2024 at 2 p.m. with the hospice Medical Director (Physician 1), Physician 1 stated he was not the attending physician of Patient's 1 and 2 and 12, and have not spoken and/or discussed Patient's 1,2,7 and 12's medical history with them. Physician 1 stated she determined patient was eligible for hospice care through his 20 years of experience as well as training in the medical school, reviewing patients previous hospital records and discharge planning, and following CMS (The Centers for Medicare & Medicaid Services, is a federal agency within the United States Department of Health and Human Services that administers the Medicare program) and Medicare guidelines in admitting patients in hospice service. A review of the agencys policy and procedure titled, ";Physician Services-Medical Director", revised November 2022, indicated the hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness. A review of the agencys policy and procedure titled ";Certification of Terminal Illness", revised November 2022, indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician, physician member of the interdisciplinary team and/or the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Clinical Records was met as follows: --- 1. The hospice agency failed to ensure the agency staff submitted complete clinical notes in a timely manner, and pertinent clinical records were included to reflect the care and assessment provided for seven of 13 sampled patients (Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). (Refer to L672). 2. The hospice agency failed to ensure a completed discharge summary was created upon discharge for four of eight sampled discharged patients (Patient 10, Patient 11, Patient 12, and Patient 13). (Refer to L684) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records were safeguarded from unauthorized access by any individual or hospice staff and were maintained complete and accurate.

Based on interview and record review, the hospice agency (HA) failed to ensure the agency staff submitted complete clinical notes in a timely manner, and pertinent clinical records were included to reflect the care and assessment provided for seven of 13 sampled patients (Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13). This failure resulted in patients incomplete clinical record that could lead to misinformation and lack of care and services provided to the patient. --- Findings: a. A review of Patient 7s demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated a start of care (SOC) date of 11/1/2023 with a terminal diagnosis of Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks) with early onset. A review of Patient 7's Comprehensive Nursing 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), dated 11/1/2023, indicated Patient 7 was awake, alert, oriented x 1 (to person only), had regular pulse (heart rate), had normal respirations (breathing) and clear lung sounds. The assessment was electronically signed by the Director of Patient Care Services (DPCS), on 2/9/2024, or more than three months after the assessment was conducted. A review of Patient 7s clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding Patient 7 care needs, and there was no documented evidence the initial bereavement assessment was conducted. b. A review of Patient 8s demographics indicated a start of care date of 2/21/2024, with a terminal diagnosis of unspecified Alzheimers disease. A review of Patient 8's Plan of Care (POC)/IDG (Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary) form, dated 3/2/2024, indicated the frequency of visits of skilled nurse (SN) to 1 (one) visit per week and 1 (one) as needed visit for pain, comfort and symptom management, hospice aide (HA) to two visit per week, and the MSW (Social worker) to perform an initial assessment within 5 (five) days from SOC. Spiritual counselor (SC) service was declined. The POC/IDG form has no signatures from the Medical Director, Registered Nurse, and the MSW that indicated they attended the IDG meeting. A review of Patient 8's clinical record indicated that there was no documented evidence the initial bereavement assessment was conducted. c. A review of Patient 9s demographics indicated a start of care date of 1/29/2024, with a terminal diagnosis of unspecified Alzheimers disease. A review of Patient 9's POC/IDG form, dated 3/2/2024, indicated the frequency of visits of skilled nurse to 1 (one) visit per week and 1 (one) as needed visit for pain, comfort and symptom management, and the MSW to visit once a month and 1 (one) prn (as needed) visit. SC and hospice aide services were declined. The POC/IDG form has no signatures from the Medical Director, RN, and the MSW that indicated they attended the IDG meeting. A review of Patient 9's clinical record indicated that there was no documented evidence the initial bereavement assessment was conducted. d. A closed record review of Patient 10s demographics indicated a start of care date of 11/18/2023, with a terminal diagnosis of cerebral infarction (also called a stroke, it occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to embolism (a blood clot that blocks the blood supply to an organ in the body) of right middle cerebral artery (an artery that supplies blood to the brain). A review of Patient 10's Comprehensive Nursing Assessment, dated 11/18/2023, indicated Patient 10 was awake, alert, oriented x 2 (to place and person), had regular pulse, had normal respirations and was bedbound. The assessment was completed and signed by a licensed vocational nurse (LVN 1), on 2/6/2024, or more than 2 (two) and a 1/2 (half) months after the assessment was conducted. A review of Patient 10s clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding Patient 10 care needs, there was no documented evidence the initial bereavement assessment was conducted, and the narrative section of the discharge summary form was blank and was not signed by the documenting nurse. e. A closed record review of Patient 11s demographics indicated a start of care date of 11/1/2023 with a terminal diagnosis of myocarcardial infarction (or heart attack, a blockage of blood flow to the heart muscle) type 2. A review of Patient 11's Comprehensive Nursing Assessment, dated 11/1/2023, indicated Patient 11 was awake, alert, oriented x 3 (to time, place, and person), had regular pulse, had normal respirations, and had no cardiac-related pain. The assessment was signed and completed by the DPCS on 3/11/2024, or more than four months after the assessment was conducted. A review of Patient 11s clinical record indicated there was no plan of care developed and completed that included specific goals and interventions regarding Patient 11 care needs, there was no documented evidence the initial bereavement assessment was conducted, and the discharge summary was not signed by the documenting nurse. f. A closed record review of Patient 12s demographics indicated a start of care date of 12/5/2023 with a terminal diagnosis of unspecified Alzheimers disease. A review of Patient 12s POC Summary form indicated no frequency of visits was ordered for all IDG (or Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary that includes a RN, SN, MSW, and SC) members. A review of Patient 12's clinical record indicated that there was no documented evidence the initial comprehensive nursing and bereavement assessment was conducted, and the narrative section of the discharge summary form was blank and was not signed by the documenting nurse. g. A closed record review of Patient 13s demographics indicated a start of care date of 11/1/2023 with a terminal diagnosis of malignant neoplasm (a cancerous tumor) of unspecified site of unspecified female breast. A review of Patient 13s POC Summary form indicated no frequency of visits was ordered for all IDG members. A review of Patient 13s Discharge Summary form indicated Patient 13 was discharged from the HA, on 1/1/2024, due to patients death. The narrative section of the discharge summary was blank, and the form was not signed by the documenting nurse. During a concurrent interview and record review with the DPCS, on 3/14/2024 at 12:50 p.m., the DPCS stated comprehensive assessment should be completed, documented, and signed within 5 (five) days from the start of hospice care and service. DPCS stated the comprehensive nursing assessment should be completed and signed by a registered nurse and not by a licensed vocational nurse. DPCS further stated patients POC should be developed on admission based on the comprehensive assessment, and all patients discharged from hospice care should have a completed discharge summary which includes the signature of the documenting nurse. DPCS acknowledged and confirmed the findings that Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 13 had incomplete clinical records. A review of the agencys policy and procedure titled, ";Entries into the Clinical Record," revised November 2022, indicated hospice personnel providing direct patient care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided. Signature authorization of clinical documentation will include the staff members name and credentials. All entries into the clinical record will reflect the date care was provided, including the month, day, and year.

Based on interview and record review, the hospice agency (HA) failed to ensure a completed discharge summary was created upon discharge for four of eight sampled discharged patients (Patient 10, Patient 11, Patient 12, and Patient 13). This deficient practice had the potential to result in miscommunication and poor hand-off and can affect the care and services needed in the continuation of care for the affected patient. --- Findings: a. A closed record review of Patient 10s demographics (identifying information such as patients name, date of birth and address, along with insurance information) indicated a start of care date of 11/18/2023, with a terminal diagnosis of cerebral infarction (also called a stroke, it occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to embolism (a blood clot that blocks the blood supply to an organ in the body) of right middle cerebral artery (an artery that supplies blood to the brain). A review of Patient 10's POC Summary form indicated an order, dated 11/18/2023, for the skilled nurse frequency of visits to one visit per week and one as needed visit for pain, comfort and symptom management, and the registered nurse (RN) to conduct an initial evaluation, then every 30 days for LVN (licensed vocational nurse) supervisory visit and scheduled recertification for ongoing assessment and comfort management. SC (Spiritual counselor), MSW (Social worker), and CHHA (hospice aide) services were offered but declined. A review of Patient 10s Discharge Summary form indicated Patient 10 was discharged from the HA due to patient declined further services, and hospice service was revoked effective 2/1/2024. The narrative section of the discharge summary was blank, and the form was not signed by the documenting nurse. b. A closed record review of Patient 11s demographics indicated a start of care date of 11/1/2023 with a terminal diagnosis of myocarcardial infarction (or heart attack, a blockage of blood flow to the heart muscle) type 2. A review of Patient 11's POC Summary form indicated an order, dated 11/1/2023, for the skilled nurse frequency of visits to one visit per week and one as needed visit for pain, comfort and symptom management, and the registered nurse (RN) to conduct an initial evaluation, then every 30 days for LVN supervisory visit and scheduled recertification for ongoing assessment and comfort management. SC, MSW, and CHHA services were offered but declined. A review of Patient 11s Discharge Summary form indicated Patient 11 was discharged from the HA due to patient refused service, and hospice service was revoked effective 1/6/2024. The discharge summary was not signed by the documenting nurse. c. A closed record review of Patient 12s demographics indicated a start of care date of 12/5/2023 with a terminal diagnosis of unspecified Alzheimers disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). A review of Patient 12s POC Summary form indicated no frequency of visits was ordered for all IDG (or Interdisciplinary Group, a team responsible for the holistic care of the hospice beneficiary that includes a RN, SN, MSW, and SC) members. A review of Patient 12s Discharge Summary form indicated Patient 12 was discharged from the HA due to patient declined further services, and hospice service was revoked effective 1/3/2024. The narrative section of the discharge summary was blank, and the form was not signed by the documenting nurse. d. A closed record review of Patient 13s demographics indicated a start of care date of 11/1/2023 with a terminal diagnosis of malignant neoplasm (a cancerous tumor) of unspecified site of unspecified female breast. A review of Patient 13s POC Summary form indicated no frequency of visits was ordered for all IDG members. A review of Patient 13s Discharge Summary form indicated Patient 13 was discharged from the HA, on 1/1/2024, due to patients death. The narrative section of the discharge summary was blank, and the form was not signed by the documenting nurse. During an interview on 3/14/2024 at 12:50 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated all patients discharged from hospice care should have a completed discharge summary which includes the signature of the documenting nurse. A review of the agency's policy and procedure titled "Discharge Summary," revised November 2022, indicated all patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record.