Every finding on record at Creed Hospice, Inc

Based on interview and record review, the home health agency (HHA) failed to ensure the emergency preparedness training for staff is conducted at least annually as required. This failure had the potential for the staff to perform ineffectively during an emergency situation. Findings: During an interview with the Owner/Administrator, on 4/5/22 at 2:40 p.m., she stated she did not conduct emergency preparedness training for all the staff since January 2022 when she took over the agency from the previous owner. The Owner/Administrator was not able to provide any documented evidence emergency preparedness training had been conducted to the agency's staff. A review of the agency's policy and procedure titled, "Emergency Management," with a revised date of 4/2020 indicated the training is provided at least every two years and demonstrates staff knowledge of emergency procedures.

Based on observation, interview, and record review, the hospice agency failed to ensure that the Condition of Participation regarding Patients' rights was met as follows: 1. The hospice agency failed to inform three of 12 patients (Patient 1,2, and 3) of their rights by providing written information before admission. These patients had their own primary care physician but were admitted to the hospice agency by the attending physician from hospice without explanation or being offered the choice of retaining their own primary care physicians. The primary care physicians were not consulted regarding the patient's life expectancy, lack of terminal illness, and qualifications for the Medicare hospital benefit (refer to L501) The cumulative effect of these systemic practices resulted in the hospice agency's failure to protect the rights of admitted patients, who did not qualify for the Medicare hospice benefits.

Based on observation, interview, and record review, the hospice agency failed to inform the patients of his and her rights, and to protect and promote the exercise of their rights, by providing written information before the admission of three of 12 sample selected patients (Patients 1, 2, and 3). This deficient practice resulted in the patients being misinformed about their hospice rights. Findings: a. On 4/9/22, a review of Patient 1's electronic clinical record indicated a start of hospice care date of 11/8/2021, with a terminal diagnosis of Atherosclerosis (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) of Coronary Artery Bypass graft (CABG- a surgical procedure used to treat coronary heart disease .It diverts blood diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply's to heart), without Again Pectoris (chest pain or discomfort due to coronary artery disease). A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 11/8/2021 to 2/5/2022, indicated Patient 1's terminal diagnosis was Atherosclerosis of Coronary Artery Bypass Graft(S) without Again Pectoris". There was no documented evidence the hospice medical director or the hospice attending physician communicated with the primary physician to certify that Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of the initial Nursing Assessment visit by the Registered Nurse (RN), dated 11/8/2021, indicated Patient 1 was forgetful, functional limitation of endurance, ambulatory with the use of a cane, incontinent of bowel/bladder, requires oxygen at two Liters per minute (LPM) as needed (PRN), with activities up as tolerated/ independent in her home, has pain in both knees with a pain scale between five to 10, which is relieved by Oxycodone (treats pain) 15 milligrams (mg) one tablet orally four times a day, with imminence of death (actively dying) within 72 hours. A review of the "Initial orders and Plan of Care," dated 11/8/2021, indicated the skilled nurse (SN) visit frequency for Patient 1 was once a week and two visits as needed for symptom management, oxygen at two LPM as need and for the SN to check O2 saturation (sat) PRN for Shortness Of Breath (SOB)-call MD for oxygen at less than 88%, nursing assessment of patient/caregiver (cg) needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the Certified Hospice Health Aide to visit once a week for socialization, personal care, and light housekeeping as needed. Continued review of the Initial orders and Plan of care instructed the social worker to visit once a month to assess, evaluation of communication, coping of patient/caregiver, community resources intervention of patient and anticipatory grief needs. It also stipulated that volunteer, and spiritual care was "Declined". However, the initial orders and Plan of Care was completed by the RN and there was no signature of the physician in the "Initial orders and Plan of Care." A review of Patient 1's " Summary/Plan/Support Diagnosis," indicated Patient 1 was admitted to hospice under routine level of care for comfort, pain management and symptom management for the 1st period of 11/8/2022 to 2/5/2022. Due to patients' poor prognosis and worsening co-morbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only. It also indicated Patient 1 is eating 50-60% less, appeared generally weak and tired, requires maximum assistance with activities of daily living care and that Patient 1 is able to ambulate with short distances, 5-10 steps with assuasive device." There was no signature of the physician. On 4/1/2022, at 11:00 a.m., during a joint home visit with Director of Patient Care services (DPCS), to the patient's home, Patient 1 was observed alert, oriented and ambulating without difficulty. At 11:25 a.m., during an interview with Patient 1 she stated she walks five blocks or more with her walker and dog. Patient 1 stated she has never met the hospice MD and sees her primary physician regular. When patient 1 was informed by the surveyor of hospice criteria having less than six months to live, Patient 1 stated, Oh my God! She was not informed about hospice service, and she is not terminal, nor has she been told she has 6 months or less to live. On 4/1/22, at 12:30 p.m., the surveyor received a phone call from Patient 1 who stated she just read the hospice agency's folder and she was not told by any staff about hospice, nor does she agree with the service. Patient 1 informed the surveyor she wants to be discharged from the hospice agency. On 4/12/22, during interview with the DPCS in the conference room of the hospice agency, she was unable to provide documented evidence the agency informed Patient 1 of her rights or provided written information concerning those rights before admission to the hospice. b. On 3/3/22, a complaint investigation was initiated due to allegations Patient 2 who was diagnosed with schizoaffective disorder (extremely disordered thinking and behavior that impairs daily functioning,) was approached by the hospice agency, signed up for hospice services even though the patient is not at the end of life and that the client was given medication he does not need without being evaluated by the hospice physician. On 4/2/22, a review of Patient 2's electronic clinical record, indicated a start of hospice care date 11/6/2021, with terminal diagnoses of Heart Failure Unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the '"Physician's Certification Hospice Benefit,'' for the 1st 90 -day period, from 11/6/2021 to 2/3/2022, indicated Patient 2's terminal diagnose was Heart Failure, Unspecified. There was no documented evidence the hospice attending physician communicated with the primary physician, to certify that Patient 2 had a life expectancy of 6 months or less if the terminal illness runs it normal course. A review of the initial Nursing Assessment by RN dated 11/6/2021, indicated Patient 2 is oriented, depressed, anxiety, has functional limitation of endurance and ambulating, fatigues easily and with imminence of death within 72 hours. A review of the "Initial orders and Plan of Care," dated 11/8/2021, indicated the SN visit frequency for Patient 2 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the social worker to visit once a month to assess, evaluation of communication, coping of patient/caregiver, community resources, intervention of patient and anticipatory grief needs. The chaplain was instructed to visit once a month to assess and evaluate. It also indicated that volunteer services were "Declined". However, admission orders, the initial orders and Plan of Care was completed by the RN and there was no signature of the physician in the admission order or the Initial orders and Plan of Care. On 4/12/22, during interview with the DPCS in the conference room of the hospice agency, she was unable to provide documented evidence the agency informed Patient 1 of her rights or provided written information concerning those rights before admission to the hospice. c. On 4/9/22, a review of Patient 3's electronic clinical record indicated a start of hospice care date of 11/6/2021, with a terminal diagnosis of Atherosclerotic Heart Disorder of Native Coronary artery without Again Pectoris. A review of the " Physician's Certification for Hospice Benefit," for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 3's terminal diagnoses was Atherosclerotic Heart Disorder of Native Coronary artery without again pectoris. On 4/5/22 at 11:02 a.m., during a telephone interview with the hospice agency's Medical Doctor (MD) regarding determining hospice criteria, he stated he reviews the supporting evidence to determine hospice from records from the hospital, records from primary doctors, labs, diagnostic records, reviews the chart, discuss it with the RN, see patient on face time and document in the chart. The agency hospice MD stated he has not had time to document or approve orders and has been behind in signing in the charts. The MD stated he thought the staff notifies the patients primary physician. The DPCS and Administrator was asked to provide all supporting evidence, such as labs, records from the primary doctor, diagnostic results that the MD stated he reviewed for the sample patients. They were unable to find the documents requested.

Based on observation, interview and record review, the hospice agency failed to ensure the Conditions of Participations regarding initial and Comprehensive Assessments of Patients was met as followed: 1. The hospice agency staff failed to conduct and document comprehensive assessment identifying the need for hospice care and services for six out of 11 sample selected patients (Patient 1, 2, 8, 9, 10 and 11). Patient 1 and 2 had no documentation of an imminent death and Patient 11 did not have a terminal diagnosis. These patients did not have life an expectancy of six months or less, and had no documented need for physical, psychosocial, emotional, or spiritual care. The agency failed to assess and document how many patients met the admission criteria for the Medicare hospice benefit. (Refer to L 521). 2. The hospice agency failed to ensure the comprehensive assessment identified the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that addressed the hospice patient's well-being, comfort, and dignity throughout the dying process for one of 12 patients (Patient 6). Patients 6's pain level was not assessed before and after pain medications was given. (Refer to L 524). 3. The hospice staff failed to review all medications the patients were taking and update the medication profiles with the currently used medications for five of 12 sample selected patients (Patients 4, 5, 9, and 10). The patients were at risk for medication errors and adverse drug reactions. (Refer to L 530). 4. The hospice agency failed to ensure an initial bereavement assessment was done for 10 out of 12 sample selected patients (Patient 1, 2, 4, 5, 6, 7, 8, 9, 10, and 11), which focused on the social spiritual, and cultural factors that may affect the ability of the family and other individuals involved in the care, to cope with the patients' death. (Refer to L 531). 5. The hospice agency failed to ensure the interdisciplinary group (IDG) met and updated the comprehensive assessment at least every 15 days for three out of 12 sample patients (Patients 1, 2, and 11) who did not meet the hospice criteria. (Refer to L 533). The cumulative effect of these systemic practices resulted in the hospice agency admitting patients who did not meet admission criteria and did not qualify for the Medicare hospice benefit.

Based on observation, interview, and record, the hospice agency staff failed to conduct and accurate comprehensive assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for six of 12 sample selected patients. (Patient 1, 2, 8, 9, 10 and 11). 1. Patients 1, 2, and 11 did not have terminal diagnoses or life expectancy of six months or less. 2. Patient 8 had no evidence of loss of ambulatory ability, 3. Patients 9 and 10 had no documented evidence of 10% weight loss These deficient practices resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life. Findings: 1a. On 4/9/22, a review of Patient 1's electronic clinical record indicated a start of hospice care date of 11/8/21, with a terminal diagnosis of atherosclerosis (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow), coronary artery bypass graft (CABG- a surgical procedure used to treat coronary heart disease. It diverts blood diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supplies to heart), without angina pectoris (chest pain or discomfort). A review of the "Physician's Certification for Hospice Benefit," for the first 90- day period from 11/8/2021 to 2/5/2022, indicated Patient 1's terminal diagnosis was atherosclerosis of Coronary Artery Bypass Graft(S) without Angina Pectoris." There was no documented evidence the hospice medical director or the hospice attending physician communicated with the primary physician to certify that Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of the initial, Nursing Assessment, visit by the RN, dated 11/8/2021, indicated Patient 1 was forgetful, functional limitation of endurance, ambulatory with the use of a cane, incontinent of bowel/bladder, requires oxygen (O2) at two Liters per minute (LPM) as needed (PRN), with activities up as tolerated/ independent in her home, has pain in both knees with a pain scale between 5 to 10, which is relieved by Oxycodone 15 milligrams (mg) 1 tablet orally four times a day, with imminence of death within 72 hours. A review of the, "Initial orders and Plan of Care," dated 11/8/2021, indicated the Skilled Nurse (SN) visit frequency for Patient 1 was once a week and two visits as needed for symptom management, O2 at two LPM as needed and for the SN to check O2 saturation (sat) PRN for shortness of breath (SOB)-call Medical Doctor (MD) for O2 sat less than 88%, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/caregiver care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the Certified Hospice Health Aide to visit once a week for socialization, personal care, and light housekeeping as needed. The Social worker to visit once a month to assess, evaluation of communication, coping of patient/caregiver, community resources, intervention of patient and anticipatory grief needs. It also stipulated that a volunteer, and spiritual care was "Declined". However, the initial orders and Plan of Care was completed by the registered nurse (RN) and there was no signature of the physician in the "Initial orders and Plan of Care." A review of Patient 1's, "Summary/Plan/Support Diagnosis," indicated patient was admitted to hospice under routine level of care for comfort, pain management and symptom management for the 1st period of 11/8/21 to 2/5/22, Due to patients' poor prognosis and worsening comorbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted that of services of hospice comfort care, pain management and symptom management only. It also indicated Patient 1 is eating 50-60% less, appeared generally weak and tired, requires maximum assistance with activities of daily living care and that Patient 1 can ambulate with short distances, 5-10 steps with assistive device. There was no documented signature of the physician. On 4/1/2022, at 11:00 a.m., during a joint home visit with Director of Patient Care services (DPCS), to the patient's home, Patient 1 was observed alert, oriented and ambulating without difficulty. On 4/1/2022 at 11:25 a.m., during an interview, Patient 1stated she walks five blocks or more with her walker and dog. Patient 1 stated the agency staff did not inform and offer the volunteer or spiritual service. When the Evaluator explained about the volunteer program, Patient 1 stated she would like to have volunteer service. Patient 1 stated she has never met the hospice MD and sees her primary physician regularly. Patient 1 was informed of hospice criteria having less than six months to live, Patient 1 stated, oh my god! She was not informed about hospice service, and she is not terminal, nor has she been told she has six months or less to live. On 4/1/22, at 12:30 p.m., the surveyor received a phone call from Patient 1 who stated she just read the hospice agency's folder and she was not told by any staff about hospice, nor does she agree with the service. Patient 1 informed the surveyor she wants to be discharged from the hospice agency. On 4/5/22, during a concurrent record review and interview with the DPCS in the conference room of the hospice agency, she stated the agency does not have IDG meeting, and that Patient 1 should have been re-evaluated. There was no documented evidence the agency informed Patient 1 of her rights or provided written information concerning those rights before admission to the hospice. 1b. On 3/3/22, a complaint investigation was initiated due allegations Patient 2 is diagnosed with schizoaffective disorder (extremely disordered thinking and behavior that impairs daily functioning) and was approached by the hospice agency to signed up for hospice services even though Patient 2 was not at the end of life and that the client was given medication he does not need without being evaluated by the hospice physician. A review of Patient 2's electronic clinical record, indicated a start of hospice care date was 11/6/21, with terminal diagnoses of Heart Failure Unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the '"Physician's Certification Hospice Benefit, '' for the 1st 90 -day period, from 11/6/21 to 2/3/22, indicated Patient 2's terminal diagnosis was Heart Failure, Unspecified. There was no documented evidence the hospice attending physician communicated with the primary physician, to certify that Patient 2 had a life expectancy of six months or less if the terminal illness runs it normal course. A review of the initial Nursing Assessment visit by the registered Nurse (RN) dated 11/6/21, indicated Patient 2 was oriented, depressed, had anxiety, had functional limitation of endurance and ambulation, and fatigues easily and with imminence of death within 72 hours. A review of the "Initial orders and Plan of Care," dated 11/6/2021, indicated the SN visit frequency for Patient 2 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the social worker to visit once a month to assess, evaluation. The chaplain was instructed to visit once a month to assess and evaluate. It also indicated that volunteer services were "Declined". However, admission orders, the initial orders and Plan of Care was completed by the RN and there was no signature of the physician in the admission order or the Initial orders and Plan of Care. A review of Patient 2's "Summary/Plan/Support Diagnosis," indicated Patient was admitted to hospice under routine level of care for comfort, pain management and symptom management for the 1st period of 11/6/21 to 2/3/22. Due to patients' poor prognosis and worsening comorbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only. It also indicated Patient 2 is eating 50-60% less, appeared generally weak and tired, requires maximum assistance with activities of daily living care and that Patient 2 is able to ambulate with short distances, five to10 steps with assistive device." There was no documented signature of the physician. 1c. A review of Patient 11's electronic clinical record, indicated a start of hospice care date of 1/11/22, with terminal diagnoses of Heart Failure Unspecified. A review of the '"Physician's Certification Hospice Benefit, '' for the 1st 90 -day period, from 1/6/22 to 2/3/22, indicated Patient 11's terminal diagnosis was Heart Failure, Unspecified. The" Physician's Narrative," indicated "due to patients' poor prognosis and worsening comorbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only." There is no documented evidence the hospice medical director or the hospice attending physician communicated with the primary physician to certify that Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of the initial Nursing Assessment visit by RN 2 dated 11/6/21, indicated Patient 11 is forgetful, depressed with anxiety, has functional limitation of ambulation and incontinent of bowel/bladder, with musculoskeletal pain/cramps, weakness related to shortness of breath and nerve pain, and fatigues easily. Pain assessment indicated Patient 11 had bilateral ankle/nerve pain, with a pain scale between three to 10, which is treated with Gabapentin 300 milligrams (mg) three capsule four times a day and with rest/relaxation and massage. A review of the "Initial orders and Plan of Care," dated 11/6/2021, indicated the SN visit frequency for Patient 11 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/caregiver care plan/intervention in collaboration with the IDT. It instructed the social worker to visit once a month to assess and evaluate. The chaplain was instructed to visit once a month to assess and evaluate. It also indicated that volunteer services were "Declined." However, admission orders, the initial orders and Plan of Care was completed by the RN and there was no signature of the physician in the admission order or the Initial orders and Plan of Care. A review of Patient 11's, " Summary/Plan/Support Diagnosis," indicated "Patient was admitted to hospice under routine level of care for comfort, pain management and symptom management for the 1st period of 11/6/21 to 2/3/22, Due to patients' poor prognosis and worsening comorbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only. It also indicated Patient 11 is eating 50-60% less, appeared generally weak and tired, requires maximum assistance with activities of daily living care and that Patient 11 is able to ambulate with short distances, five to 10 steps with assistive device." There was no documented signature of the physician. A review of Skilled Nursing noted completed by the DPCS dated 2/2/22, indicated under reason for record indicated discharge. There was no documented reason for discharge on the form. The rest of the SN notes were blank with no signatures from the DPCS or IDG. On 4/5/22 at 11:02 a.m., during a telephone interview with the hospice agency's MD regarding determining hospice criteria, he stated he reviews the supporting evidence such as records from the hospital, records from primary doctors, labs, diagnostic records, reviews the chart, discusses it with the RN, see patients on face time and documents in the chart. The hospice agency's MD stated he has not had time to document or approve orders and has been really behind on signing the charts. The MD stated he thought the agency's staff notifies the patients primary physician. The DPCS and Administrator was asked to provide all supporting evidence, such as labs, records from the primary doctor, diagnostic results that the MD stated he reviewed for the sample patients. They were unable to find the documents requested. During an interview with the DPCS, on 2/12/22 at 2: 20 p.m., she stated the end of care summary should have been completed by the IDG, however the agency has not had IDG meeting since she started at the agency on 1/16/2022 and that no discipline is involved in the IDG including the Medical Doctor. Review of the hospice agency's policy and procedure Titled, Discharge Criteria, revised 11/2017, indicated, "The Medical Director and/or attending physician determine the patient is not hospice-appropriate, according to standards clinical criteria for determining disease prognosis of six (6) months or less. Continued review or the hospice policy and procedure under stipulates, 1. The hospice interdisciplinary group will develop a discharge plan which includes the possibility that a patient's condition might stabilize or change such that the patient cannot be certified s terminally ill. The discharge planning process will include any necessary family counseling, patient education or other services needed prior to discharge. 2. The hospice Case Manager will ensure that the necessary paperwork completed at the time of discharge. This will include a signed revocation form, if necessary, and completion of discharge summary. 4. Documentation will fill in clinical record. Information will be documented on a discharge/transfer form, which is to be completed within 72 hours." 2. A review of Patient 8's admission record indicated the patient was admitted on 1/8/22, with a primary diagnosis of Alzheimer's disease. During a home visit, on 4/1/22 at 9:05 a.m., Patient 8 was observed waking from the living room sofa to the kitchen. Patient 8 was walking steadily, with a slow gait. During an interview, on 4/1/22 at 1:45 p.m., Patient 8's Primary Physician (PP) stated she was not aware Patient 8 was receiving hospice care. PP stated she has been taking care of Patient 8 since 10/25/06. PP stated Patient 8 did not have a terminal illness and was expected to live longer than one year. The PP stated Patient 8's current condition, he will decline, but he is not bed bound, he's not there yet. The PP stated his disease is not severe. A review of Patient 8's medical record titled, "Functional Assessment Staging." dated 1/8/22, indicated " ...7 Severe Dementia 7c Ambulatory ability is lost." 3a. A review of Patient 9's admission record indicated the patient was admitted on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a chronic lung condition causing difficulty in breathing). During a home visit, on 4/1/22 at 8:40 a.m., with DPCS, Patient 9 was observed greeting the DPCS at the front door. Patient 9 was observed walking around the home steadily, with a slow gait. During an interview, on 4/1/22 at 1:45 p.m., Patient 9's PP stated she was not aware Patient 9 was receiving hospice care. PP stated she has been taking care of Patient 9 from 1998-2014, then again in the beginning 2/22. PP stated Patient 9 did not have a terminal illness and was expected to live longer than one year. A review of Patient 9's medical record titled, "Guidelines for determining prognosis due to pulmonary disease," dated 2/13/22, indicated " ...4.Unintentional progressive weight (wt.) loss of greater than 10% of body weight over the preceding six months." During a concurrent interview and record review, on 4/5/22 at 12:36 p.m. with the DPCS, Patient 9's medical record from the agency dated 2/13/22, was reviewed. The record indicated, "Wt.: Current" blank, Previous 0.00 pounds (lbs.)". The DPCS stated, "we need to do our own assessment of weight. We should weigh the patient." 3b. A review of Patient 10's admission record indicated the patient was admitted on 3/2/22 with a primary diagnosis of COPD. A review of Patient 10's medical record titled, "Guidelines for determining prognosis due to pulmonary disease," dated 3/2/22, indicated " ...4.Unintentional progressive weight loss of greater than 10% of body weight over the preceding six months." During a concurrent interview and record review, on 4/5/22 at 12:21 p.m. with the DPCS, Patient 10's medical record from the agency dated 3/2/22, was reviewed. The record indicated "Wt.: Current blank, Previous 0.00 lbs." The DPCS stated, "we need to do our own assessment of weight. We should weigh the patient." A review of the agency's policy and procedures titled, "Admission Criteria and Process," dated 04/2018, indicated, the agency will admit a patient only on recommendation of the medical director in consultation with, or input from, the patient's attending physician, if any ...3. The patient must have a life-limiting illness with a life expectancy of six (6) months or less, as determined by the attending physician and hospice Medical Director.

Based on observation, interview and record review, The Hospice Agency (HA) failed to ensure comprehensive assessment including vital signs, height, weight, and oxygen saturation (the fraction of oxygen-saturated hemoglobin relative to total hemoglobin in the blood- normal pulse oximeter readings usually range from 95 to 100 percent) was conducted to the patients for eight of 13 sampled patients (Patient 4, 5, 6, 7, 8, 10, 11 and 12). This deficient practice could have placed the patient at risk of distress by not identifying the patient's condition/status. Findings: b. A review of Patient 5's clinical record indicated, the patient started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) visit was once a week and as needed. The Medical Social Worker (MSW) visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. A review of the POC/IDG Review dated 12/28/2021 to 8/29/2022 indicated the assessment of vital signs (blood pressure, pulse, temperature, respiration rate), height weight, MAC were not included in the POC/IDG. It indicated to assess oxygen saturation rate as needed. A review of the Comprehensive Nursing Assessment indicated there was no following assessment on following days: * 12/28/2021 -no height and weigh, no MAC * 3/27/2022 - no temperature, no pulse no blood pressure, no height and weight, no MAC * 6/24/2022 - no temperature, no pulse, no blood pressure, no height and weight, no MAC, no oxygen saturation rate * 8/22/2022 - no temperature, no pulse no blood pressure, no height and weight, no MAC, no oxygen saturation rate c. A review of Patient 6's clinical record indicated, the patient started hospice care on 7/14/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit once per 2 weeks plus one visit and LVN visit once per week and one visit as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of the Comprehensive Nursing Assessment and RN visit Note indicated the spaces for following assessment was blank on following days: * 7/14/2021 - no height, no weight, no MAC *6/17/2022 - no temperature, no pulse, no blood pressure, no weight, no MAC *6/24/2022 - no temperature, no pulse, no blood pressure, no weight, no MAC *7/1/2022 to 8/5/2022- no temperature, no pulse, no blood pressure, no weight, no MAC, no oxygen saturation rate. * 8/19/2022 and 9/2/2022 - no oxygen saturation rate d. A review of Patient 7's clinical record indicated, the patient started hospice care on 2/8/22, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit two times per 2 weeks plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's RN visit note and LVN visit note indicated the spaces for following assessment were blank on following days: *Comprehensive assessment -5/3/2022 and 8/6/2022 - no temperature, no pulse, no blood pressure, no MAC, no oxygen saturation rate * LVN visit note from 4/1/2022 to 6/2/2022 - no temperature, no pulse, no blood pressure * LVN visit note from 5/5/2022 to 5/26/2022 - no oxygen saturation rate. * RN visit note from 6/9/2022 to 6/30/2022 - no temperature, no pulse, no blood pressure e. A review of Patient 8's clinical record indicated, the patient started hospice care on 1/21/22, with a terminal diagnosis of COPD. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated the RN visits for initial assessment, supervisory visit, and ongoing comprehensive assessment, reassessment, recertification and as needed. The Skilled Nurse (SN) visit once a week and onece per week as needed. The MSW was to visit within 5 days from the SOC, Certification and as needed. The HA service and the volunteer services were offered and declined. A review of Patient 8's RN visit note dated 7/4/2022, 7/11/2022, 7/18/2022 indicated the spaces for blood pressure, pulse and temperature were blank. During an interview with the Director of Patient Care Services (DPCS), she was not able to provide the documented evidence the above assessment was performed for Patient 5, 6, 7, 8 on above days, and stated the assessment should have been done. A review of the agency's policy titled " Comprehensive Assessment" revised in April 2017 indicated, all baseline data and other relevant information will be documented in the patient's clinical record including at least a physical assessment, including blood pressure, temperature, pulse, respiration skin, and other relevant data related to pertinent physical findings and the patient's terminal illness. A review of the agency's policy titled "Ongoing Comprehensive Assessment" revised in April 2017 indicated the nurse will assess the patient on each visit, for vital signs appropriate to the patient's condition.

Based on observation, interview and record review, the hospice staff failed to review all medications the patients were taking and update the medication profiles with the currently used medications for five of 12 sample selected patients (Patients 4, 5, 9, and 10). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. Findings: a. A review of Patient 4's admission record indicated the patient was admitted to the hospice agency on 3/16/2022, with primary diagnosis of Alzheimer's disease (affects memory, thinking and behavior). A review of the "Initial orders and Plan of Care," dated 3/16/2022, indicated the SN visit frequency for Patient 4 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). The space for administration and education on medication was not check marked. On 4/1/2022, at 10:45 a.m., during a joint home visit with Hospice Aide 1 (HA 1), Patient 4 was observed lying in a bed and Family member 2 was next to the Patient 4. During Patient 4's medication review comparing the medication profile, with Family member 2, the following discrepancies were verified: 1. Tylenol 325 milligrams (mg) - Patient 4 had a container labeled to take one tablet two times a day, while the medication profile indicated to take once a day. 2. Carbidopa/Levodopa 25/100 - Patient 4 had a container labeled to take one tablet two times a day, while the medication profile indicated to take once a day (treats Parkinson's disease [a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination]). 3. Metoprolol 25 mg - Patient 4 had a container labeled to take one tablet two times a day, while the medication profile indicated to take once a day (treats chest pain or high blood pressure). 4. Timolol Maleate 0.5 % - Patient 4 had a container labeled to take one drop two times a day, while the medication profile indicated to take one drop once a day (used to treat high pressure in the eye). 5. Ferrous Sulfate (220 mg/5 milter[ml]) - Patient 4 had a container of Ferrous Sulfate labeled to take 7.5 ml once a day, while the medication profile indicated to take one tablet once a day (iron vitamin). 6. Vitamin B complex - Patient 4 had a bottle of Vitamin B complex, while the medication profile indicated Vitamin B 12 to take one tablet once a day (vitamin). During an interview with Family member 2, on 4/2/22 at 11:20 a.m., he stated Tylenol 325 mg, Carbidopa/Levodopa 25/100, Metoprolol 25 mg, Timolol Maleate 0.5 %, had been administered two times a day as instructed by the physician's office. Family Member 2 further stated Ferrous Sulfate had been administered 7.5 ml and the patient never had Vitamin B 12. b. A review of Patient 5's admission record indicated the patient was admitted to the hospice agency on 1/12/2022, with primary diagnosis of Atherosclerotic heart disease (buildup of fats in the artery walls). A review of the "Initial orders and Plan of Care," dated 1/12/2022, indicated the SN visit frequency for Patient 5 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). The space for administration and education on medication was not check marked. On 4/1/2022, at 11:55 a.m., during a joint home visit with the Administrator and the DPCS, Patient 5 was observed lying in a bed and Family member 3 was next to the Patient 5. During Patient 5's medication review with the DPCS compared with the medication profile, following was verified: 1. Alphagan 0.1 5 ophthalmic drop was expired in January 2022 (eye medication to treat high pressure in the eye). 2. Lasix 20 mg - Patient 5 had a container labeled to take one tablet two times a day, while the medication profile indicated to take one tablet daily (treats fluid retention in the body). 3. Levothyroxine 100 microgram (mg) (dated 6/21/2021) - Patient 5 had a container labeled to take one tablet two times a day, while it was not indicated in the medication profile (a medicine used to treat an underactive thyroid gland). 4. Levothyroxine 150 mcg (dated 10/18/2021)- Patient 5 had a container labeled to take one tablet two times a day, while the medication profile indicated to take one tablet once a day. 5. Levothyroxine 175 mcg (dated 11/4/2021) - Patient 5 had a container labeled to take one tablet two times a day, while it was not indicated in the medication profile. During an interview with Family member 3 with translation by the administrator, he stated he had been administered Lasix 20 mg one tablet two times a day and Levothyroxine 150 mcg one tablet two times a day. When asked whether Levothyroxine 100 mcg (dated 6/21/2021) and Levothyroxine 175 mcg (dated 11/4/2021) were discontinued, Family member 3 stated he did not know. He stated he had been administered Levothyroxine 150 mcg one tablet two times a day, instead of updated prescription (Levothyroxine 175 mcg - dated 11/4/2022). At 12:55 p.m., during a telephone interview with Registered Nurse (RN 1), she stated she had checked the medications, but did not notice the discrepancies and did not clarify with the physician. During a concurrent interview with the DPCS, she stated the SN should have physically checked the patients' medication comparing with the medication profile, should have clarified with the physician, and provided education to the patient/caregiver. A review of the agency's policy titled " Medication profile, " with a revised date of 4/2020, indicated the patients' receiving medications administered by 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. c. A review of Patient 8's admission record indicated the patient was admitted on 1/8/22, with a primary diagnosis of Alzheimer's disease. During a home visit, on 4/1/22 at 9:05 a.m., with DPCS, Patient 8 was observed walking from the living room to the kitchen. Family member 4, next of kin, was present during the SN visit. During the visit, the DPCS did not review the medications Patient 8 was taking. d. A review of Patient 9's admission record indicated the patient was admitted on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a chronic lung condition causing difficulty in breathing). During a home visit, on 4/1/22 at 8:40 a.m., Patient 9 was observed walking around the home steadily, slow gait. During a home visit, on 4/1/22 at 8:40 a.m., with DPCS, Patient 9 was observed greeting the DPCS at the front door. Family member 4, next of kin to Patient 9, was present during the SN visit. During the visit, the DPCS did not review the medications Patient 9 was taking. During an interview, on 4/1/22 at 9:25 a.m., the DPCS stated, "No, I did not check medication for Patient 8 and Patient 9, I forgot to. We are supposed to do medication reconciliation every visit because we need to know if there's a change." A review of the agency's policy and procedure titled, "Medication Profile," dated April 2020, indicated, "Patients receiving medications administered by the hospice will have a current, accurate medication profile in the clinical record."

b. On 4/9/22, a review of Patient 1's electronic clinical record indicated a start of hospice care date of 11/8/21, with a terminal diagnosis of Atherosclerosis (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) of Coronary Artery Bypass graft (CABG- a surgical procedure used to treat coronary heart disease .It diverts blood diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply's to heart),without Again Pectoris (chest pain or discomfort due to coronary artery disease). A review of the "Initial orders and Plan of Care" dated 11/8/21, indicated the Skilled Nurse (SN) visit frequency for Patient 1 was once a week and two visits, the Social worker to visit once a month to assess, evaluation of communication, coping of patient/caregiver, community resources, intervention of patient and anticipatory grief needs. There was no documented evidence of bereavement assessment for Patient 1. c. On 4/2/22, a review of Patient 2's electronic clinical record, indicated a start of hospice care date 11/6/21, with terminal diagnoses of Heart Failure Unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the "Initial orders and Plan of Care" dated 11/6/21, indicated the SN visit frequency for Patient 2 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/caregiver care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the social worker to visit once a month to assess, evaluation. The chaplain was instructed to visit once a month to assess and evaluate. There was no documented evidence of bereavement assessment for Patient 2. Based on interview and record review the facility failed to conduct or attempt to conduct a bereavement assessment to provide bereavement counseling in accordance with the patient/family's needs for 10 of 12 sample selected patients (Patients 1, 2, 4, 5 ,6, 7, 8, 9, 10, and 11). This deficient practice had the potential for the patient/family not being provided social, spiritual, and cultural support related to the patient's death. Findings: a. A review of clinical record of Patient 4, 5, 6, and 7 indicated there was no documented evidence of a bereavement assessment was conducted or attempted to conduct. On 4/4/2022, at 2:35 p.m., during a telephone interview with the medical social worker (MSW), she stated she had not been conducting bereavement assessment/services, because the Chaplain was to provide bereavement assessment/service. The Team was not able to conduct an interview with the Chaplain. On 4/5/2022, at 4 p.m., during an interview with the Director of Patient Care Services (DPCS) she stated the agency had a Chaplain. However, she was not able to provide the documented evidence the Chaplain had performed bereavement assessment or contacted the patient/caregiver for explanation of benefit of the spiritual care service to perform spiritual assessment. A review of the agency's undated policy titled "Bereavement Assessment," indicated on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the bereavement coordinator. The Bereavement Coordinator will review the bereavement risk assessment to determine potential needs of the survivors. A review of the agency's undated policy and procedure titled "Bereavement Services," indicated the program will provide bereavement services to the family/caregiver of hospice patients, before and after the patient's death, in accordance with the plan of care. d. A review of Patient 8's admission record indicated the patient was admitted to on 1/8/22, with a primary diagnosis of Alzheimer's disease (disease that destroys memory and other important mental functions.). Further review of the medical record did not indicate a bereavement assessment was done. e. A review of Patient 9's admission record indicated the patient was admitted to on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a chronic lung condition causing difficulty in breathing). Further review of the medical record did not indicate a bereavement assessment was done. f. A review of Patient 10's admission record indicated the patient was admitted on 3/2/22 with a primary diagnosis of COPD. Further review of Patient 10's medical record from the agency, dated 3/3/22, indicated "Need for Comprehensive Assessment: Bereavement." Continued review of the medical record did not indicate a bereavement assessment was done. During an interview, on 4/4/22, on 2:36 p.m., the MSW stated she did not do bereavement assessments. The MSW stated the Chaplain was responsible for the bereavement assessments. The MSW stated she just assesses quickly, but she did not go into a deep assessment because that is the chaplain's work. g. On 4/2/22, a review of Patient 11's electronic clinical record, indicated a start of hospice care date of 1/11/22, with terminal diagnoses of Heart Failure Unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the "Initial orders and Plan of Care" dated 11/6/2021, indicated the SN visit frequency for Patient 11 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with IDT. It instructed the social worker to visit once a month to assess, evaluation. The chaplain was instructed to visit once a month to assess and evaluate. Review of the chaplain's visit note dated 1/15/22 was blank. There was no documented evidence of bereavement assessment for Patient 11. During a telephone interview with the hospice agency's Social Worker, on 4/4/22 at 2:36 p.m., she stated she does not do bereavement assessment the chaplain does. Multiple attempts contact the chaplain was done, however, the chaplain never responded to the calls. A review of the hospice agency's undated policy and procedures titled, "Bereavement Services", indicated "A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice." A review of the hospice agency's undated policy and procedure on Bereavement Services indicated, "A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Information gathered will be incorporated into a plan of care and considered in the bereavement plan of care.

Based on observation, interview and record review, the agency failed to ensure the interdisciplinary group (IDG) met and updated the comprehensive assessment at least every 15 days for three out of 12 sample selected patients (Patient 1, 2, and 11). This deficient practice had potential for harm if patients are prevented from reaching their goals, due to IDG not addressing changes in the patient's condition. Findings: a. On 4/9/22, a review of Patient 1's electronic clinical record indicated a start of hospice care date of 11/8/21, with a terminal diagnosis of Atherosclerosis (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) of Coronary Artery Bypass graft (CABG- a surgical procedure used to treat coronary heart disease .It diverts blood diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply's to heart),without Again Pectoris (chest pain or discomfort due to coronary artery disease). A review of Patient 1's clinical record indicated Patient 1 has been on hospice in her second benefit period of a total of 153 days. A review of the comprehensive assessment and recertification to hospice completed by Registered Nurse (RN 2) indicated there was no IDG signatures and no documented evidence of an evaluation of Patient 1 response to care, treatment, services provided and there was no progress toward desired outcome documented every 15 days. b. On 4/2/22, a review of Patient 2's electronic clinical record, indicated a start of hospice care date of 11/6/21, with terminal diagnoses of Heart Failure Unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of Patient 2's clinical record indicated Patient 2 of a total of 125 days. A review of the comprehensive assessment and recertification to hospice completed by RN 2 indicated there was no IDG signatures and no documented evidence of an evaluation of Patient 2 response to care, treatment, services provided and there was no progress toward desired outcome documented every 15 days. c. On 4/2/22, a review of Patient 11's electronic clinical record, indicated a start of hospice care date of 1/11/22, with terminal diagnoses of Heart Failure Unspecified. A review of the comprehensive assessment and recertification to hospice completed by RN 2 indicated there was no IDG signatures and no documented evidence of an evaluation of Patient 11 response to care, treatment, services provided and there was no progress toward desired outcome documented every 15 days.

Based on record review and staff interview, the hospice agency failed to designate an interdisciplinary group (IDG) ,in consultation with the patients physician, in preparing the written plan of care (POC) for 11 of 11 sample patients. There was no evidence the physician was consulted in the development of the plan of care and the MSW, and Chaplain had participated in preparing the POC . Patient 6 POC did not include pain assessment. This deficient practice could potentially prevent the patients from reaching their care planning goals. Findings: a. On 4/9/22, a review of Patient 1's electronic clinical record indicated a start of hospice care date of 11/8/21, with a terminal diagnosis of Atherosclerosis( The build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow)of Coronary Artery Bypass graft (CABG- a surgical procedure used to treat coronary heart disease .It diverts blood diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply's to heart),without Again Pectoris ( chest pain or discomfort due to coronary artery disease). A review of the " Physician's Certification for Hospice Benefit" for the first 90- day period from 11/8/2021 to 2/5/2022, indicated Patient 1's terminal diagnoses was Atherosclerosis of Coronary Artery Bypass Graft(S) without Again Pectoris". There was no documented evidence of interdisciplinary group meeting minutes. A review of Patients POC/Interdisciplinary group dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, there were no more IDG notes in Patient 1's electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 1's care plan. b. On 4/2/22, a review of Patient 2's electronic clinical record, indicated a start of hospice care date 11/6/21, with terminal diagnoses of Heart Failure Unspecified( a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the '"Physician's Certification Hospice Benefit '' for for the 1st 90 -day period, from 11/6/21 to 2/3/22, indicated Patient 2's terminal diagnose was Heart Failure, Unspecified. There was no documented evidence the hospice attending physician communicated with the primary physician, to certify that Patient 2 had a life expectancy of 6 months or less, if the terminal illness runs it normal course. A review of Patients POC/Interdisciplinary group dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, there were no more IDG notes in patient 2's e;electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 2's care plan. c. On 4/9/22, a review of Patient 3's electronic clinical record indicated a start of hospice care date of 11/6/21, with a terminal diagnosis of Atherosclerotic Heart Disorder Of Native Coronary artery without Again Pectoris s( The build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) without chest pain or discomfort due to coronary artery disease). A review of the " Physician's Certification for Hospice Benefit" for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 3's terminal diagnoses was Atherosclerotic Heart Disorder of Native Coronary artery without again pectoris. A review of Patients POC/Interdisciplinary group dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, there were no more IDG notes in patient 3's electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 3's care plan. k. On 4/2/22, a review of Patient 11's electronic clinical record, indicated a start of hospice care date 1/11/22, with terminal diagnoses of Heart Failure Unspecified( a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the " Physician's Certification for Hospice Benefit" for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 1's terminal diagnoses was Atherosclerotic Heart Disorder of Native Coronary artery without again pectoris. A review of Patients POC/Interdisciplinary group dated 1/11/22, 1/25/22, there were no more IDG notes in patient 1's e;electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 3's care plan. During a telephone interview with the social worker on 4/4/22, she stated she does not attend the IDG meeting . During an interview with the DPCS on 2/5/22, at 2: 20 pm, stated the hospice and all disciplines in the IDG has not had IDG meeting since she started at the agency on 1/16/2022 and that no discipline is involved in the IDG including the Medical Doctor. Review of the agency's policy and procedure on Interdisciplinary Group Meetings revised 11/2017, stipulates," the Interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes in progress and update to the plan of care, deaths and changes in the patient and family/caregiver circumstances, referrals, andadmission/certification and recertification of patients on the hospice program. Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. The meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present,including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose and that the discussion is confidential. Based on interview and record review, the hospice agency failed to develop the Plan of care (POC) with participation of all members of Interdisciplinary group (IDG) for 11 of 11 sampled patients (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11). This deficient practice can prevent completing comprehensive/individualized plan of care and prevent providing care/service the patients needed. Findings: d. A review of Patient 4's admission record indicated the patient was admitted to the hospice agency on 3/16/2022, with primary diagnosis of Alzheimer's disease (chronic neurodegenerative disease that starts slowly and worsens over time). A review of the "Initial orders and Plan of Care" dated 3/16/2022, indicated there were the physician's name and the RN 1's name typed. However, there were no signatures of the physician, RN 1, social worker, spiritual care, and date. A review of the "IDG Plan of Care & Review of Comprehensive Assessment" dated 3/22/2022 indicated the spaces of signature for the Physician, RN, social worker, spiritual care and the date were blank. On 4/4/2022, at 1:35 p.m., during a telephone interview with RN 1, she stated she was never included in the IDG meeting. e. A review of Patient 5's admission record indicated the patient was admitted to the hospice agency on 1/12/2022, with primary diagnosis of Atherosclerotic heart disease. A review of the "Initial orders and Plan of Care" dated 1/12/2022, indicated there were the physician's name and the registered name typed. However, there were no signatures of the physician, RN, social worker, spiritual care, and date. A review of the "IDG Plan of Care & Review of Comprehensive Assessment" dated 1/25/2022, 2/8/2022, 2/22/2022, 3/8/2022, 3/22/2022 indicated the spaces of signature for the Physician, RN, social worker, spiritual care and the date were blank. f. A review of Patient 6's record indicated the start of care date was 11/22/2021, with diagnoses of malignant neoplasm of cervix uteri, anemia, and chronic kidney disease. Patient 6 discharged on 12/8/2021. A review of the "Initial Orders and plan of care (POC)" dated 11/22/2021, indicated the physician and the RN signed electronically on 11/22/2022. However, there were no signatures for the social worker, spiritual care. g. A review of Patient 7's record indicated the start of care date was 11/18/2021, with diagnoses of Stage III chronic kidney disease. A review of the "Initial Orders and plan of care (POC)" dated 11/18/2021, indicated there were the physician's name and the registered name typed. However, there were no signatures of the physician, RN, social worker, spiritual care, and date. A review of the "IDG Plan of Care & Review of Comprehensive Assessment" dated 11/30/2021, 12/14/2021, 12/28/2021, 1/11/2022, 1/25/2022, 2/8/2022, 2/22/2022, 3/8/2022, 3/22/2022 indicated the spaces of signature for the Physician, RN, social worker, spiritual care and the date were blank. On 4/5/2022, at 11:50 a.m., during an interview with the Director of Patient Care Services (DPCS), she stated when the disciplines electronically signed it should be printed as "E-signed" with the date. The DPCS was not able to provide the documented evidence all the IDG member had participated in IDG meeting and coordinated to develop the POC on above days for above patients. A review of the agency's policy and procedure titled "The Plan of Care" revised in November 2017 indicated the plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group. A review of the agency's policy titled "Interdisciplinary Group Meeting"revised in November 2017 indicated the hospice Medical Director and all hospice interdisciplinary group member will be present, including volunteers and attending physician, as available. The members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice clinical supervisor/Nursing supervisor. h. A review of Patient 8's admission record indicated the patient was admitted to the HA on 1/8/22, with a primary diagnosis of Alzheimer's disease. A review of Patient 8's medical record titled, "IDT Plan of Care & Review of Comprehensive Assessment" indicated as follows: "IDT meeting 1/11/22 ...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care RN Name, Signature, Date", DPCS E-signed on 1/11/22. No other names indicated on the record. "IDT meeting 1/25/22 ...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care RN Name, Signature, Date", DPCS E-signed on 2/8/22. No other names indicated on the record. "IDT meeting 2/22/22 ...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care RN Name, Signature, Date", DPCS E-signed on 2/22/22. No other names indicated on the record. "IDT meeting 3/22/22 ...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care RN Name, Signature, Date", DPCS E-signed on 3/22/22. No other names indicated on the record. i.A review of Patient 9's admission record indicated the patient was admitted to the HA on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 9's medical record titled, "IDT Plan of Care & Review of Comprehensive Assessment" indicated as follows: "IDT meeting 2/22/22 ...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care RN Name, Signature, Date", DPCS E-signed on 2/22/22. No other names indicated on the record. "IDT meeting 3/8/22 ...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care RN Name, Signature, Date", DPCS E-signed on 3/8/22. No other names indicated on the record. "IDT meeting 3/22/22 ...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care RN Name, Signature, Date", DPCS E-signed on 3/22/22. No other names indicated on the record. j. A review of Patient 10's admission record indicated the patient was admitted to the HA on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 10's medical record titled, "IDT Plan of Care & Review of Comprehensive Assessment" indicated, "IDT meeting 3/22/22 ...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care RN Name, Signature, Date", DPCS E-signed on 3/22/22. No other names indicated on the record. During an interview on 4/4/22, at 1:23 p.m., the DPCS stated the Chaplain, Social Worker, Hospice Medical Director, and her is supposed to be involved in the IDT. The DPCS stated "we haven't been doing it for a while. I don't remember when it was the last time. I know IDT meetings you are supposed to report condition of all patients." A review of the HA's policy and procedure titled, "Interdisciplinary Group Meeting", dated November 2017, indicated "the meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available."

Based on interview and record review, the agency staff failed to ensure the plan of care (POC) include pain management for a patient who had pain and was diagnosed with malignant neoplasm of cervix for one of 11 sample patients (Patient 6). This deficient practice allowed the patient to suffer with pain. Findings: A review of Patient 6's record indicated the start of care date was 11/22/2021, with diagnoses of malignant neoplasm of cervix uteri, anemia, and chronic kidney disease. A review of the Registered Nurse (RN) Assessment, dated 11/22/2021, indicated Patient 6 had sharp, dull generalized pain, and pain on the cervix with the pain level of 5 on a pain scale from zero to ten (5/10). It indicated the best pain level was 1/10, the worst pain level was 7/10, and acceptable pain level was 3/10/ The pain relief measure included rest/relaxation, massage and administration of Oxycodone as needed. A review of the "Initial Orders and plan of care (POC)" dated 11/22/2021, indicated the SN visit frequency for Patient 6 was once a week and one visit as needed per week for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT), and administration and education on medication. However, the POC did not indicate about pain management such as ongoing pain assessment, providing verbal or written information regarding the effective pain relief, providing education to patients and families related to their roles in managing pain and potential limitations. During an interview with the Director of Patient Care Services (DPCS) on 4/4/2022, at 2:35 p.m., she was not able to provide the documented evidence pain management was included in the POC. The DPCS stated the pain management should have been included in the POC. A review of the agency's policy and procedure titled "The Plan of Care" revised in November 2017 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.

Based on record review and staff interview, the hospice agency failed to designate an interdisciplinary group (IDG) ,in consultation with the patients physician, in preparing the written plan of care (POC) for 11 of 11 sample patients. There was no evidence the physician was consulted in the development of the plan of care and the MSW, and Chaplain had participaed in preparing the POC . Patient 6 POC did not include pain assessment. This deficient practice could potentially prevent the patients from reaching their care planning goals. Findings: a. On 4/9/22, a review of Patient 1's electronic clinical record indicated a start of hospice care date of 11/8/21, with a terminal diagnosis of Atherosclerosis( The build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow)of Coronary Artery Bypass graft (CABG- a surgical procedure used to treat coronary heart disease .It diverts blood diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply's to heart),without Again Pectoris ( chest pain or discomfort due to coronary artery disease). A review of the " Physician's Certification for Hospice Benefit" for the first 90- day period from 11/8/2021 to 2/5/2022, indicated Patient 1's terminal diagnoses was Atherosclerosis of Coronary Artery Bypass Graft(S) without Again Pectoris". There was no documented evidence of interdisciplanary group meeting minutes. A review of Patients POC/Interdisciplanry group dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, there were no more IDG notes in Patient 1's electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physicia, MSW, chaplain participated in developing Patient 1's care plan. b. On 4/2/22, a review of Patient 2's electronic clinical record, indicated a start of hospice care date 11/6/21, with terminal diagnoses of Heart Failure Unspecified( a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the '"Physician's Certification Hospice Benefit '' for for the 1st 90 -day period, from 11/6/21 to 2/3/22, indicated Patient 2's terminal diagnose was Heart Failure, Unspecified. There was no documented evidence the hospice attending physician communicated with the primary physician, to certify that Patient 2 had a life expectancy of 6 months or less, if the terminal illness runs it normal course. A review of Patients POC/Interdisciplanry group dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, there were no more IDG notes in patient 2's e;ectronoc clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physicia, MSW, chaplain participated in developing Patient 2's care plan. c. . On 4/9/22, a review of Patient3's electronic clinical record indicated a start of hospice care date of 11/6/21, with a terminal diagnosis of Atherosclerotic Heart Disorder Of Native Coronary artery without Agina Pectoris s( The build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) without chest pain or discomfort due to coronary artery disease). A review of the " Physician's Certification for Hospice Benefit" for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 3's terminal diagnoses was Atherosclerotic Heart Disorder of Native Coronary artery without agina pectoris. A review of Patients POC/Interdisciplanry group dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, there were no more IDG notes in patient 3's electronoc clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physicia, MSW, chaplain participated in developing Patient 3's care plan. k. On 4/2/22, a review of Patient 11's electronic clinical record, indicated a start of hospice care date 1/11/22, with terminal diagnoses of Heart Failure Unspecified( a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the " Physician's Certification for Hospice Benefit" for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 1's terminal diagnoses was Atherosclerotic Heart Disorder of Native Coronary artery without agina pectoris and A review of Patients POC/Interdisciplanry group dated 1/11/22, 1/25/22, there were no more IDG notes in patient 1's e;ectronoc clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physicia, MSW, chaplain participated in developing Patient 3's care plan. During a telephone interview with the social worker on 4/4/22, she stated she does not attend the IDG meeting . During an interview with the DPCS on 2/5/22, at 2: 20 pm, stated the hospice and all disciplines in the IDG has not had IDG meeting since she started at the agency on 1/16/2022 and that no discipline is involved in the IDG including the Medical Doctor. Review of the agency's policy and procedure on Interdisciplinary Group Meetings revised 11/2017, stipulates," the Interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes in progress and update to the plan of care, deaths and changes in the patient and family/caregiver circumstances, referrals, andadmission/certification and recertification of patients on the hospice program. Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. The meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present,including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose and that the discussion is confidential. Based on record review and interview, the hospice agency failed to include at the minimum individuals [a physician, a registered nurse (RN), a social worker (SW), and a pastor or other counselor] who are qualified and competent in the interdisciplinary group (IDG) meetings to discuss the patients family/caregiver changes and progress and to update the plan of care for 11 of 11 sampled patients (Patient 1, 2, 3, 4, 5, 6, 8, 9, 10, 11). This deficient practice had a potential to result in lacking continuous assessment and care planning that meet patients' needs, and the patients' changes/ problems might not be adequately acted on by the appropriate and qualified staff, to ensure the patient goals are met. Findings: d. A review of Patient 4's admission record indicated the patient was admitted to the hospice agency on 3/16/2022, with primary diagnosis of Alzheimer's disease (chronic neurodegenerative disease that starts slowly and worsens over time). A review of the "Initial orders and Plan of Care" dated 3/16/2022, indicated there were the physician's name and the RN 1's name typed. However, there were no signatures of the physician, RN 1, social worker, spiritual care, and date. A review of the "IDG Plan of Care & Review of Comprehensive Assessment" dated 3/22/2022 indicated the spaces of signature for the Physician, RN, social worker, spiritual care and the date were blank. On 4/4/2022, at 1:35 p.m., during a telephone interview with RN 1, she stated she was never included in the IDG meeting. e. A review of Patient 5's admission record indicated the patient was admitted to the hospice agency on 1/12/2022, with primary diagnosis of Atherosclerotic heart disease. A review of the "Initial orders and Plan of Care" dated 1/12/2022, indicated there were the physician's name and the registered name typed. However, there were no signatures of the physician, RN, social worker, spiritual care, and date. A review of the "IDG Plan of Care & Review of Comprehensive Assessment" dated 1/25/2022, 2/8/2022, 2/22/2022, 3/8/2022, 3/22/2022 indicated the spaces of signature for the Physician, RN, social worker, spiritual care and the date were blank. f. A review of Patient 6's record indicated the start of care date was 11/22/2021, with diagnoses of malignant neoplasm of cervix uteri, anemia, and chronic kidney disease. Patient 6 discharged on 12/8/2021. A review of the "Initial Orders and plan of care (POC)" dated 11/22/2021, indicated the physician and the RN signed electronically on 11/22/2022. However, there were no signatures for the social worker, spiritual care. g. A review of Patient 7's record indicated the start of care date was 11/18/2021, with diagnoses of Stage III chronic kidney disease. A review of the "Initial Orders and plan of care (POC)" dated 11/18/2021, indicated there were the physician's name and the registered name typed. However, there were no signatures of the physician, RN, social worker, spiritual care, and date. A review of the "IDG Plan of Care & Review of Comprehensive Assessment" dated 11/30/2021, 12/14/2021, 12/28/2021, 1/11/2022, 1/25/2022, 2/8/2022, 2/22/2022, 3/8/2022, 3/22/2022 indicated the spaces of signature for the Physician, RN, social worker, spiritual care and the date were blank. On 4/5/2022, at 11:50 a.m., during an interview with the Director of Patient Care Services (DPCS), she stated when the disciplines electronically signed it should be printed as "E-signed" with the date. The DPCS was not able to provide the documented evidence all the IDG member had participated in IDG meeting and coordinated to develop the POC on above days for above patients. A review of the agency's policy and procedure titled "The Plan of Care" revised in November 2017 indicated the plan of care will be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group. A review of the agency's policy titled "Interdisciplinary Group Meeting"revised in November 2017 indicated the hospice Medical Director and all hospice interdisciplinary group member will be present, including volunteers and attending physician, as available. The members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice clinical supervisor/Nursing supervisor. h. A review of Patient 8's admission record indicated the patient was admitted to the HA on 1/8/22, with a primary diagnosis of Alzheimer's disease. A review of Patient 8's medical record titled, "IDT Plan of Care & Review of Comprehensive Assessment", did not indicate the Hospice Medical Director, MSW, and the Chaplain attended IDT meetings on 1/11/22, 1/25/22, 2/22/22, and 3/22/22. i.A review of Patient 9's admission record indicated the patient was admitted to the HA on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 9's medical record titled, "IDT Plan of Care & Review of Comprehensive Assessment", did not indicate the Hospice Medical Director, MSW, and the Chaplain attended IDT meetings on 2/22/22, 3/8/22, and 3/22/22. j. A review of Patient 10's admission record indicated the patient was admitted to the HA on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 10's medical record titled, "IDT Plan of Care & Review of Comprehensive Assessment", did not indicate the Hospice Medical Director, MSW, and the Chaplain attended IDT meetings on 3/22/22. During an interview on 4/4/22, at 1:23 p.m., the DPCS stated the Chaplain, Social Worker, Hospice Medical Director, and her is supposed to be involved in the IDT. During an interview on 4/4/22, at 1:52 p.m., HR stated "No, I do not attend IDT" During an interview on 4/4/22, at 2:36 p.m., the MSW stated "NO, I cannot attend IDT meeting on Tuesdays. Sometimes, I give the information directly to the nurse, or CEO". A review of the HA's policy and procedure titled, "Interdisciplinary Group Meeting", dated November 2017, indicated " ...The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available."

Based on interview and record review, the agency failed to ensure the plan of care were developed with all the members of hospice interdisciplinary group in collaboration with the patient or caregiver for 11 of 11 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11). This deficient practice can result to poor-quality care provided to all the patients under the agency's care and can affect each patient's quality of life. Findings: a. On 4/9/2022, during a review of Patient 1's electronic clinical record, indicated a start of hospice care date of 11/8/2021, with a terminal diagnosis of atherosclerosis (The build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow), coronary artery bypass graft (CABG- a surgical procedure used to treat coronary heart disease that diverts blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply's to heart), without angina pectoris ( chest pain or discomfort due to coronary artery disease). A review of the " Physician's Certification for Hospice Benefit" for the first 90- day period from 11/8/2021 to 2/5/2022, indicated Patient 1's terminal diagnosis was atherosclerosis of Coronary artery bypass graft without again pectoris". A review of Patient 1's POC (plan of care) /Interdisciplinary group document dated 11/16/2021, 11/30/2021, 12/4/2021, 12/28/2021, 1/11/2022, 1/25/2022, did not indicate interdisciplinary group meeting (IDG, a group of health care professionals coordinating toward a common goal for the patient's plan of care) notes in his electronic clinical record and did not indicate a physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW (social worker), chaplain participated in developing Patient 1's care plan. b. On 4/2/2022, a review of Patient 2's electronic clinical record, indicated a start of hospice care date 11/6/2021, with terminal diagnoses of heart failure unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the '"Physician's Certification Hospice Benefit '' for the 1st 90 -day period, from 11/6/2021 to 2/3/2022, indicated Patient 2's terminal diagnoses was heart failure, unspecified. There was no documented evidence the hospice attending physician communicated with the primary physician, to certify that Patient 2 had a life expectancy of 6 months or less if the terminal illness runs it normal course. A review of Patient 2's POC/Interdisciplinary group document dated 11/16/2021, 11/30/2021, 12/4/2021, 12/28/2021, 1/11/2022, 1/25/2022, did not indicate the IDG notes in Patient 2's electronic clinical record and the IDG notes did not indicate a physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 2's care plan. c. On 4/9/2022, a review of Patient 3's electronic clinical record indicated a start of hospice care date of 11/6/2021, with a terminal diagnosis of atherosclerotic heart disorder of native coronary artery without angina pectoris. A review of the " Physician's Certification for Hospice Benefit" for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 3's terminal diagnoses was atherosclerotic heart disorder of native coronary artery without again pectoris. A review of Patient 3's POC/Interdisciplinary group document dated 11/16/2021, 11/30/2021, 12/4/2021, 12/28/2021, 1/11/2022, 1/25/2022, did not indicate the IDG notes in Patient 3's electronic clinical record and did not indicate the physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 3's care plan. d. A review of Patient 4's admission record indicated the patient was admitted to the hospice agency on 3/16/2022, with primary diagnosis of Alzheimer's disease (chronic neurodegenerative disease that starts slowly and worsens over time). A review of the "Initial orders and Plan of Care" dated 3/16/2022, indicated the physician's name and the Registered Nurse 1's (RN) name typed. However, there were no date and signatures of the physician, RN 1, social worker, spiritual care. A review of the "IDG Plan of Care & Review of Comprehensive Assessment" dated 3/22/2022 indicated the spaces of signature for the Physician, RN, social worker, spiritual care and the dates were blank. On 4/4/2022, at 1:35 p.m., during a telephone interview with RN 1, she stated she was never included in the IDG meeting. e. A review of Patient 5's admission record indicated the patient was admitted to the hospice agency on 1/12/2022, with primary diagnosis of Atherosclerotic heart disease. A review of the "Initial orders and Plan of Care" dated 1/12/2022, indicated physician's name and the registered name typed. However, there were no signatures of the physician, RN, social worker, spiritual care, and date. A review of the "IDG Plan of Care & Review of Comprehensive Assessment" dated 1/25/2022, 2/8/2022, 2/22/2022, 3/8/2022, 3/22/2022 indicated the spaces of signature for the Physician, RN, social worker, spiritual care and the dates were blank. f. A review of Patient 6's record indicated the start of care date was 11/22/2021, with diagnoses of malignant neoplasm (tumor) of cervix uteri, anemia (low blood count), and chronic kidney disease (kidney damage). Patient 6 was discharged on 12/8/2021. A review of the "Initial Orders and plan of care (POC)" for Patient 6 dated 11/22/2021, indicated the physician and the RN signed electronically on 11/22/2022. However, there were no signatures of the social worker and spiritual care. g. A review of Patient 7's record indicated the start of care date was 11/18/2021, with diagnoses of Stage III chronic kidney disease. A review of the "Initial Orders and plan of care (POC)" for Patient 7 dated 11/18/2021, indicated the physician's name and the RN's name typed. However, there were no signatures of the physician, RN, social worker, spiritual care, and date. A review of the "IDG Plan of Care & Review of Comprehensive Assessment" dated 11/30/2021, 12/14/2021, 12/28/2021, 1/11/2022, 1/25/2022, 2/8/2022, 2/22/2022, 3/8/2022, 3/22/2022 did not indicate signatures of the Physician, RN, social worker, and spiritual counselor, and had no date. On 4/5/2022, at 11:50 a.m., during an interview with the Director of Patient Care Services (DPCS), she stated when the disciplines electronically signed it should be printed as "E-signed" with the date. The DPCS was not able to provide the documented evidence of all the IDG members who had participated in IDG meeting and coordinated to develop the POC on above days for above patients. A review of the hospice agency's policy and procedure titled "The Plan of Care" revised in November 2017 indicated the plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group. A review of the agency's policy titled "Interdisciplinary Group Meeting "revised in November 2017 indicated the hospice Medical Director and all hospice interdisciplinary group member will be present, including volunteers and attending physician, as available. The members at the interdisciplinary group meeting will sign an attendance form that will be kept by the hospice clinical supervisor/Nursing supervisor. h. A review of Patient 8's admission record indicated the patient was admitted to the agency on 1/8/2022, with a primary diagnosis of Alzheimer's disease (severe memory impairment). A review of Patient 8's medical record titled "Initial Orders and Plan of Care", for certification period 1/8/2022 to 4/7/2022, indicated "orders for discipline and treatment SN (skilled nurse) visit 1st week 1 visits, 2 PRN (as needed) visits for pain and symptom management. Further review of the record indicated Patient 8 was scheduled to be seen by the nurse on 3/26/2022 and 4/1/2022. There were no clinical notes in Patient 8's record of these visits. i.A review of Patient 9's admission record indicated the patient was admitted to the agency on 2/13/2022, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, a chronic lung condition causing difficulty in breathing). A review of Patient 9's medical record titled "Initial Orders and Plan of Care, for certification period 2/13/2022-5/13/2202, indicated "orders for discipline and treatment SN 1st week 1 visits and 2 PRN visits for pain and symptom management. Further review of the record indicated Patient 9 was scheduled to be visited by the nurse on 3/24/2022 and 3/31/2022. There were no clinical notes in Patient 9's record of these visits. j. A review of Patient 10's admission record indicated the patient was admitted to the agency on 3/2/2022 with a primary diagnosis of COPD. A review of Patient 10's medical record titled "Initial Orders and Plan of Care, for certification period 3/2/2022-5/30/2022, indicated "orders for discipline and treatment SN 1st week 1 visits and 2 PRN visits for pain and symptom management. Further review of the record indicated Patient 10 was scheduled to be visited by the nurse on 3/16/2022, 3/18/2022, 3/25/2022 and 3/30/2022. There were no clinical notes in Patient 10's record of these visits. During an interview on 4/4/2022, at 2:52 p.m., the DPCS the expectation is to document on the patient record. The DPCS stated "if it was not documented, it was not done". A review of the hospice agency's policy and procedure titled, "Plan of Care", dated November 2017, indicated " Care provided to the patient will be in accordance with the plan of care." k. On 4/2/2022, a review of Patient 11's electronic clinical record, indicated a start of hospice care date 1/11/2022, with terminal diagnoses of heart failure unspecified. A review of the " Physician's Certification for Hospice Benefit" for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 1's terminal diagnoses was atherosclerotic heart disorder of native coronary artery without again pectoris and a review of Patient 11's POC/Interdisciplinary group document dated 1/11/2022, 1/25/2022, did not indicate the IDG notes in Patient 1's electronic clinical record and did not indicate a physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 3's care plan. During a telephone interview with the social worker on 4/4/2022, she stated she does not attend the IDG meeting. During an interview with the DPCS on 2/5/2022 at 2: 20 pm, DPCS stated the hospice and all disciplines in the IDG has not had IDG meeting since she started at the agency on 1/16/2022 and that no discipline is involved in the IDG including the Medical Doctor. A review of the agency's policy and procedure titled "Interdisciplinary Group Meetings", revised 11/2017, indicated the Interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes in progress and update to the plan of care, deaths and changes in the patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient's plan of care 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. The meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose and that the discussion is confidential.

Based on interview and record review, the hospice agency (HA) failed to ensure its interdisciplinary group (IDG) reviewed and revised the patient's care plans in consultation with the physician, social worker, chaplain for seven of 11 sampled patients (Patients 1,2,3,8,9,10 and 11). This deficient practice resulted the IDG not reviewing the patients' care plans which had the potential for not identifying the changes in the progress and not updating the plan of care. Findings: a. A review of Patient 1's electronic clinical record indicated a start of hospice care date of 11/8/21, with a terminal diagnosis of atherosclerosis ( a build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) of coronary artery bypass graft (CABG, a surgical procedure used to treat coronary heart disease. It diverts blood diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply's to heart), without angina pectoris (chest pain or discomfort due to coronary artery disease). A review of Patient 1's "Physician's Certification for Hospice Benefit" for the first 90 day period from 11/8/2021 to 2/5/2022, indicated Patient 1's terminal diagnosis was atherosclerosis of coronary artery bypass graft(S) without angina pectoris. There was no documented evidence of interdisciplinary group meeting minutes. A review of Patient 1's POC/Interdisciplinary group dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, indicated there were no more IDG notes in Patient 1's electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain that participated in developing Patient 1's care plan. b. A review of Patient 2's electronic clinical record, indicated a start of hospice care date 11/6/21, with terminal diagnoses of Heart Failure Unspecified( a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the '"Physician's Certification Hospice Benefit '' for for the 1st 90 -day period, from 11/6/21 to 2/3/22, indicated Patient 2's terminal diagnosis was heart failure, unspecified. There was no documented evidence the hospice attending physician communicated with the primary physician, to certify that Patient 2 had a life expectancy of 6 months or less, if the terminal illness runs it normal course. A review of Patient 2's POC/Interdisciplinary group dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, there were no more IDG notes in Patient 2's electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 2's care plan. c. A review of Patient 3's electronic clinical record indicated a start of hospice care date of 11/6/21, with a terminal diagnosis of atherosclerotic heart disorder of native coronary artery without angina pectoris. A review of Patient 3's" Physician's Certification for Hospice Benefit" for the first 90 day period from 11/6/2021 to 2/3/2022, indicated Patient 3's terminal diagnosis was atherosclerotic heart disorder of native coronary artery without again pectoris. A review of Patient 3's POC/Interdisciplinary group dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, there were no more IDG notes in patient 3's electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 3's care plan. d. On 4/2/22, a review of Patient 11's electronic clinical record, indicated a start of hospice care date 1/11/22, with terminal diagnosis of heart failure, unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of Pateint 11's" Physician's Certification for Hospice Benefit" for the first 90 day period from 11/6/2021 to 2/3/2022, indicated Patient 1's terminal diagnosis was atherosclerotic heart disorder of native coronary artery without angina pectoris. A review of Patient 11's POC/Interdisciplinary group dated 1/11/22, 1/25/22, there were no more IDG notes in Patient 11's electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 3's care plan. During a telephone interview with the social worker on 4/4/22, she stated she does not attend the IDG meeting. During an interview with the DPCS on 2/5/22, at 2: 20 pm, stated the hospice and all disciplines in the IDG has not had IDG meeting since she started at the agency on 1/16/2022 and that no discipline is involved in the IDG including the Medical Doctor. A review of the agency's policy and procedure on Interdisciplinary Group Meetings revised 11/2017, stipulates," the Interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes in progress and update to the plan of care, deaths and changes in the patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient's plan of care 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. The meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present, including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose and that the discussion is confidential. e. A review of Patient 8's admission record indicated the patient was admitted to the HA on 1/8/22, with a primary diagnosis of Alzheimer's disease ((a progressive disease that destroys memory and other important mental functions). A review of Patient 8's medical record titled, "IDT Plan of Care & Review of Comprehensive Assessment", did not indicate the Hospice's Medical Director, MSW, and the chaplain attended IDT meetings on 1/11/22, 1/25/22, 2/22/22, and 3/22/22. f. A review of Patient 9's admission record indicated the patient was admitted to the HA on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 9's medical record titled, "IDT Plan of Care & Review of Comprehensive Assessment", did not indicate the Hospice Medical Director, MSW, and the Chaplain attended IDT meetings on 2/22/22, 3/8/22, and 3/22/22. No further IDT meetings were documented in the patients record. g. A review of Patient 10's admission record indicated the patient was admitted to the HA on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. A review of Patient 10's medical record titled, "IDT Plan of Care & Review of Comprehensive Assessment" indicated, "IDT meeting 3/22/22 ...The following IDT members updated/reviewed the Interdisciplinary Team Plan of Care RN Name, Signature, Date", DPCS E-signed on 3/22/22. No further IDT meetings were documented in the patients record. During an interview on 4/4/22, at 1:23 p.m., the DPCS stated IDT meeting were supposed to be every two weeks, on Tuesdays. The DPCS stated "we haven't been doing it for a while. I don't remember when it was the last time. I know that IDT meetings, you are supposed to report condition of all patients." A review of the HA's policy and procedure titled, "Interdisciplinary Group Meeting", dated November 2017, 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. "

Based on interview and record review, the hospice agency (HA) failed to ensure the interdisciplinary group maintained the responsiblity for directing, coordinating, and supervising the care and services for seven of 11 sampled patients (Patients 1,2,3,8,9,10 and 11). This deficient practice resulted in the HA's clnical staff not being aware of the changes in teh care provided to the patients. Findings: a. A review of Patient 1's electronic clinical record indicated a start of hospice care date of 11/8/21, with a terminal diagnosis of atherosclerosis ( a build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) of coronary artery bypass graft (CABG, a surgical procedure used to treat coronary heart disease .It diverts blood diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply's to heart), without angina pectoris ( chest pain or discomfort due to coronary artery disease). A review of Patient 1's "Physician's Certification for Hospice Benefit" for the first 90 day period from 11/8/2021 to 2/5/2022, indicated Patient 1's terminal diagnoses was atherosclerosis of coronary artery bypass graft(S) without angina pectoris." There was no documented evidence of interdisciplinary group meeting minutes. A review of Patient 1's POC/Interdisciplinary group (IDG) dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, indicated there were no more IDG notes in Patient 1's electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 1's care plan. b. A review of Patient 2's electronic clinical record, indicated a start of hospice care date 11/6/21, with terminal diagnoses of heart failure, unspecified ( a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of Patient 2's '"Physician's Certification Hospice Benefit'' for for the 1st 90 day period, from 11/6/21 to 2/3/22, indicated Patient 2's terminal diagnosis was heart failure, unspecified. There was no documented evidence the hospice attending physician communicated with the primary physician, to certify that Patient 2 had a life expectancy of 6 months or less, if the terminal illness runs it normal course. A review of Patients POC/Interdisciplinary group dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, there were no more IDG notes in Patient 2's electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 2's care plan. c. A review of Patient 3's electronic clinical record indicated a start of hospice care date of 11/6/21, with a terminal diagnosis of atherosclerotic heart disorder of native coronary artery without angina pectoris ( a build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) without chest pain or discomfort due to coronary artery disease). A review of Patient 3's "Physician's Certification for Hospice Benefit" for the first 90 day period from 11/6/2021 to 2/3/2022, indicated Patient 3's terminal diagnosis was atherosclerotic heart disorder of nativecCoronary artery without angina pectoris. A review of Patient 3's POC/Interdisciplinary group dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, indicated there were no more IDG notes in Patient 3's electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 3's care plan. d. A review of Patient 11's electronic clinical record, indicated a start of hospice care date 1/11/22, with terminal diagnoses of Heart Failure Unspecified( a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of Patient 11's "Physician's Certification for Hospice Benefit" for the first 90 day period from 11/6/2021 to 2/3/2022, indicated Patient 11's terminal diagnosis was atherosclerotic heart disorder of native coronary artery without angina pectoris and A review of Patient 11's POC/Interdisciplinary group dated 1/11/22, 1/25/22, indicated there were no more IDG notes in Patient 11's electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 11's care plan. During a telephone interview with the social worker on 4/4/22, she stated she does not attend the IDG meeting . During an interview with the DPCS on 2/5/22, at 2: 20 pm, stated the hospice and all disciplines in the IDG has not had IDG meeting since she started at the agency on 1/16/2022 and that no discipline is involved in the IDG including the Medical Doctor. A Review of the agency's policy and procedure on Interdisciplinary Group Meetings revised 11/2017, stipulates," the Interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes in progress and update to the plan of care, deaths and changes in the patient and family/caregiver circumstances, referrals, and admission/certification and recertification of patients on the hospice program. Each patient's plan of care 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. The meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present,including volunteers and attending physicians, as available. The patient and family/caregiver will be informed of the schedule for this meeting, its purpose and that the discussion is confidential. e. A review of Patient 8's admission record indicated the patient was admitted to the HA on 1/8/22, with a primary diagnosis of Alzheimer's disease. A review of Patient 8's medical record titled, "IDT Plan of Care & Review of Comprehensive Assessment", did not indicate the hospice's medical director, MSW, and the Chaplain attended IDT meetings on 1/11/22, 1/25/22, 2/22/22, and 3/22/22. f. A review of Patient 9's admission record indicated the patient was admitted to the HA on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 9's medical record titled, "IDT Plan of Care & Review of Comprehensive Assessment", did not indicate the hospice's medical director, MSW, and the Chaplain attended IDT meetings on 2/22/22, 3/8/22, and 3/22/22. g. A review of Patient 10's admission record indicated the patient was admitted to the HA on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. A review of Patient 10's medical record titled, "IDT Plan of Care & Review of Comprehensive Assessment", did not indicate the Hospice Medical Director, MSW, and the Chaplain attended IDT meetings on 3/22/22. During an interview on 4/4/22, at 1:23 p.m., the DPCS stated the Chaplain, Social Worker, Hospice Medical Director, and her is supposed to be involved in the IDT. During an interview on 4/4/22, at 1:52 p.m., HR stated "No, I do not attend IDT." During an interview on 4/4/22, at 2:36 p.m., the MSW stated "NO, I cannot attend IDT meeting on Tuesdays. Sometimes, I give the information directly to the nurse, or CEO". During an interview on 4/5/22, at 11:02 p.m., the MD stated, "we try to do it monthly", when asked about the frequency of IDT meetings. A review of the HA's policy and procedure titled, "Interdisciplinary Group Meeting", dated November 2017, indicated "The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updated to the plan of care, deaths, and changes in patient and family/caregiver circumstances, referrals admission/certification and recertification of patients.

c. A review of Patient 5's clinical record indicated the patient started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of Patient 5's Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) visit was once a week and as needed. The Medical Social Worker (MSW) visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. A review of Patient 5's record indicated there was documented evidence the skilled nurse (SN) had visited Patient 5 for the weeks from 7/3/2022 to 7/9/2022 and 8/28/2022 to 9/3/2022. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/12/2022, at 1:20 p.m., she stated she was not able to find the documented evidence the SN had visited Patient 5 on above time period. LVN 1 stated the above missed visits should have been rescheduled, but she was not able to provide the documented evidence rescheduled visit was made. d. A review of Patient 6's clinical record indicated the patient started hospice care on 7/14/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). A review of Patient 6's Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit once per 2 week plus one visit and LVN visit once per week and one visit as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 6's record indicated there was documented evidence the skilled nurse (SN) had visited Patient 6 the weeks from 8/7/2022 to 8/13/2022 and 8/21/2022 to 8/27/2022. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/12/2022, at 1:30 p.m., she stated she was not able to find the documented evidence the SN had visited Patient 6 on the above time period. LVN 1 stated the above missed visits should have been rescheduled, but she was not able to provide the documented evidence rescheduled visit was made. e. A review of Patient 7's clinical record indicated the patient started hospice care on 2/8/22, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit two times per 2 weeks plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's record indicated there was no documented evidence the skilled nurse (SN) had visited Patient 7 from 3/13/2022 to 3/26/2022 (for two weeks) and 8/12/2022 to 9/11/2022 (for four weeks). During an interview with Licensed Vocational Nurse 1 (LVN 1) on 9/12/2022, at 1:35 p.m., she stated she was not able to find the documented evidence the SN had visited Patient 7 on the above days. LVN 1 stated she could not find the reason why the SN visit was not made on above days, and could not find the documentation the above missed visit was reported to the IDG. A review of the agency's policy titled, "Miss Visit" revised in April 2017 indicated if visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit was missed and not rescheduled, the clinician would notify the IDG and clinical supervisor of the missed visit and reason for missed visit. The clinical supervisor will track the number and reasons for missed visits to assess patterns and to assure that the plans of care contain the correct number of planned visits. c. A review of Patient 8's admission record indicated the patient was admitted to the HA on 1/8/22, with a primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 8's medical record titled, "Physician Order Details" dated 1/8/22, indicated "Medical Social Worker visit frequency: services offered but not needed at this time patient and family has a good psychosocial and emotional support from family and friend. Will continue to offer services." Further review of Patient 8's medical record titled, "Creed Hospice, Inc." dated 1/8/22, indicated "Need for Comprehensive Assessment: Social work. d. A review of Patient 9's admission record indicated the patient was admitted to the HA on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 9's medical record titled, "Physician Order Details", dated 2/13/22 , indicated "MSW frequency of visits: initial psychosocial assessment within 5 days of SOC; follow up visit once a month if necessary." Further review of Patient 9's medical record titled, "Creed Hospice, Inc.", dated 2/13/22, indicated "Need for Comprehensive Assessment: Social work." Continued review of the medical record did not indicate MSW performed the initial psychosocial assessment. e. A review of Patient 10's admission record indicated the patient was admitted to the HA on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 10's medical record titled, "Physician Order Details", dated 3/2/22, indicated "MSW frequency of visit: initial psychosocial assessment within 5 days of SOC; follow up visit once a month if necessary." Further review of Patient 10's medical record titled, "Creed Hospice, Inc.", dated 3/3/22, indicated "Need for Comprehensive Assessment: Social work." Continued review of the medical record did not indicate MSW performed the initial psychosocial assessment. During an interview on 4/4/22, at 2:52 p.m., the DPCS stated "if it was not documented, it was not done." A review of the HA's policy and procedure titled, "Plan of Care", dated November 2017, indicated " ...14. Care provided to the patient will be in accordance with the plan of care."

Based on interview and record review, the hospice agency failed to: 1. Maintain and provide evidence of an ongoing hospice-wide data-driven quality assessment and performance improvement (QAPI) program and its implementation. (Refer to L560) 2. Ensure presence of the hospice's governing body and documentation that its governing body is responsible in ensuring an ongoing program for quality improvement and patient safety is defined, implemented, and maintained, and is evaluated annually. (Refer to L574) The cumulative effect of these systemic problems resulted in the hospice agency's inability to ensure the provision of a quality health care in a safe environment.

Based on interview and record review, the hospice agency (HA) failed to provide evidence that quality assessment and performance improvement (QAPI, a coordinated application of two mutually-reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI), which are critical to improving the quality of life, and quality of care and services delivered in a healthcare facility) system was formulated and ensure its program objectives, patient care disciplines, description of how the program will be administered and coordinated, methodology for monitoring and evaluating the quality of care, priorities for resolution of problems, monitoring to determine effectiveness of action, oversight responsibility reports to governing body, and documentation of the review of its own QAPI program were implemented. This deficient practice resulted in the inability of the agency to identify issues, improve health outcomes, patient safety, and quality patient care. Findings: During an interview on 4/5/2022, at 10:56 a.m., the Director of Patient Care Services (DPCS) stated the agency did not have a QAPI program. The DPCS stated she was aware that a QAPI program was needed and the QAPI program was supposed to meet at least monthly. The DPCS was unable to provide a reason why the QAPI program was not developed. A review of the HA's document titled, "Job Descriptions Director of Patient Care Services", dated November 2017, indicated, to assist with the evaluation of organization performance via quality assessment performance improvement program; assures for the quality and safe delivery of hospice services provided through the Organization."

Based on interview and record review, the hospice agency (HA) failed to provide evidence that a governing body was maintained to ensure full responsibility for the operation of the program; evaluate annually, the overall performance of the agency and ensure a policy for its governing body was formulated. This deficient practice resulted in the inability of the agency to identify issues, improve health outcomes, patient safety, and quality patient care. Findings: During an interview on 4/5/2022, at 10:57 a.m., the Administrator (ADM) stated the agency did not have a governing body. The ADM was unable to provide a reason why the agency did not have a governing body. A review of the HA's policies and procedures did not include a policy for governing body. The agency was unable to provide a policy for governing body upon request.

Based on observation, interview, and record review, the hospice agency (HA) failed to implement its COVID-19 (Coronavirus 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person) policy and procedures by failing to ensure the visitors were being screened for signs and symptoms of COVID-19 including the temperature check. This deficient practice resulted in placing the patients, staff, and visitors at risk for COVID-19 and further spread of infection that could lead to severe respiratory illness, hospitalization and/or death. Findings: During an observation on 3/31/22, at 11:00 a.m., upon entrance to the HA, there was no screening for COVID-19 signs and symptoms and no temperature check. During an observation on 4/4/22, at 09:00 a.m., upon entrance to the HA, there was no screening for COVID-19 signs and symptoms and no temperature check. During an observation on 4/5/22, at 09:00 a.m., upon entrance to the HA, there was no screening for COVID-19 signs and symptoms and no temperature check. During an interview on 4/5/22, at 12:50 p.m., the Director of Patient Care Services (DPCS) stated, "No, we did not screen you for COVID symptoms. No, we did not take your temperature. We forgot. We are supposed to do it." The DPCS stated the HA should have a log to show the visitors were screened.

Based on interview and record review the hospice agency (HA) failed to follow accepted standards of practice to prevent the transmission of infections and communicable diseases by failing to: a. Maintain documented evidence that the staff were fully vaccinated against COVID-19 (Coronavirus 19 disease, a highly, contagious respiratory illness caused by virus that spread from person to person) as indicated in the agency's policy and procedure on COVID-19. b. Ensure staff were trained on infection control to mitigate the transmission and spread of COVID-19 as indicated in the agency's policy and procedure on COVID-19. This deficient practice resulted in placing the patients, staff, and visitors at risk for COVID-19 and further spread of infection that could lead to severe respiratory illness, hospitalization and/or death. Findings: During an interview on 3/31/22, at 2:49 p.m., the Administrator (ADM) stated Human Resource (HR) staff was responsible to check employee vaccination status. can track it down." During an interview on 4/5/22, at 2:40 p.m., the DPCS stated "no we do not have it" when asked if an employee COVID-19 vaccination verification documents were available. The DPCS stated infection control and COVID-19 training had not been provided for the staff. The DPCS did not provide a reason for this. A review of the HA's policy and procedure titled, "Covid-19 ETS", dated January 2022, indicated "Procedure ...3. Shall require all vaccinated employees to provide an acceptable proof of vaccination status, including those employees who are partially or fully vaccinated ...shall maintain a record and a roster of each employee's vaccination status ...30. Each employee shall undergo training regarding COVID-19."

Based on 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 the seven of 13 sampled patients, (Patients 2,4, 5, 7, 11, 12 and 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. Findings: a. A review of Patient 2's clinical record indicated a start of care (SOC) date of 7/20/2021, with a primary diagnosis of cerebrovascular disease (a group of conditions, diseases, and disorders that affect the blood vessels and blood supply to the brain). A review of Patient 2'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), done by the Registered Nurse (RN), dated 4/4/2020, indicated Patient 2 was awake, alert, oriented. The Comprehensive Nursing Assessment indicated Patient 2 was referred to Social Work and Spiritual Care (Bereavement Counselor). A review of Patient 2's clinical record did not indicate a documented psychosocial assessment (an evaluation of the psychological and social factors that are experienced by an individual or family)was completed since SOC. b. A review of Patient 4's clinical record indicated a start of care (SOC) date of 9/22/2021, with a primary diagnosis of heart disease (heart condition). A review of Patient 4's Comprehensive Nursing Assessment, done by the RN, dated 9/22/2021, indicated Patient 4 was awake, alert, oriented to time, place, and person. The Comprehensive Nursing Assessment indicated MSW, chaplain, and volunteer services were offered. There was no documented evidence MSW had completed a psychosocial assessment on Patient 4 since SOC. During a concurrent interview and record review with the Case Auditor [Licensed Vocational Nurse (LVN) 1], on 9/12/2022 at 1:30 p.m., she was not able to provide the documented evidence the social worker had visited or conducted an assessment for Patient 2 and Patient 4. LVN 1 stated the social worker should have visited them and conducted an assessment within 5 days of admission. During an interview with the agency's Medical social worker (MSW) on 9/12/2022, at 5:26 p.m., she stated she was supposed to provide the social services to the patients in the list which was given by the agency. The MSW stated she had not visited Patient 2 and Patient 4 because the hospice agency did not include their names on her list. c. A review of Patient 5's clinical record indicated, Patient 5 started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD,a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible). It indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/Interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) visit was once a week and as needed. The Medical Social Worker (MSW) visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. During a joint home visit with RN 1 on 9/7/2022, at 10:20 a.m., Patient 5 was observed walking using a cane from her car. Patient was alert, oriented, and was able to communicate well. At 10:30 a.m., during an interview with Patient 5, she stated the social worker had not visited her several months ago. She stated she had not declined the social service. A review of Patient 5's record indicated there was no documented evidence the social worker had visited Patient 5 after initial assessment on 12/20/2021. d. A review of Patient 7's clinical record indicated, the patient started hospice care on 2/8/22, with a terminal diagnosis of COPD. A review of the POC/IDG Review dated 8/15/2022 indicated RN visit two times per 2 weeks plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's "Comprehensive Nursing Assessment" dated 2/28/2022 indicated Patient 7 was alert and oriented, the social worker visit was needed. The nursing narrative section indicated, that, as per the hospice protocol, the MSW, spiritual counselor and the bereavement counselor will call the patient and the family and offer their services. A review of Patient 7's record did not indicate a documented evidence the social worker had visited Patient 7 since 2/28/2022. During an interview with LVN 1 on 9/12/2022, at 12:55 p.m., LVN 1 was not able to find the documented evidence that the social worker had visited Patient 5 after 12/21/2021, nor a documented evidence that the social worker had visited Patient 7 since the SOC last 2/28/2022. LVN 1 stated the social worker should have visited Patient 5 and Patient 7, and should have provided social services every certification period and as needed. d. A review of Patient 8's admission record indicated the patient was admitted to on 1/8/22, with a primary diagnosis of Alzheimer's disease. A review of Patient 8's medical record titled, "Physician Order Details", dated 1/8/22, indicated "Medical Social Worker visit frequency: services offered but not needed at this time patient and family has a good psychosocial and emotional support from family and friend. Will continue to offer services." A review of Patient 8's medical record from the facility dated 1/8/22, indicated, "Need for Comprehensive Assessment: Social work." e. A review of Patient 9's admission record indicated the patient was admitted on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a chronic lung condition causing difficulty in breathing). A review of Patient 9's medical record titled, "Physician Order Details," dated 2/13/22, indicated "MSW frequency of visits: initial psychosocial assessment within five days of SOC; follow up visit once a month if necessary." A review of Patient 9's medical record from the facility dated 2/13/22, indicated "Need for Comprehensive Assessment: Social work." Further review of the medical record did not indicate MSW performed the initial psychosocial assessment. f. A review of Patient 10's admission record indicated the patient was admitted on 3/2/22 with a primary diagnosis of COPD. A review of Patient 10's medical record titled, "Physician Order Details," dated 3/2/22, indicated "MSW frequency of visit: initial psychosocial assessment within 5 days of SOC; follow up visit once a month if necessary." A review of Patient 10's medical record from the facility dated 3/3/22, indicated "Need for Comprehensive Assessment: Social work." Continued review of the medical record did not indicate MSW performed the initial psychosocial assessment. During an interview, on 4/4/22 at 2:36 p.m., the MSW stated she did a psychosocial assessment if the nurse informed her the patient wanted MSW services, within 5 days of SOC. The MSW stated when she does assess a patient she calls the nurse right away or texts them. The MSW stated she does not document her interventions, does not document what she told the nurse, or what she discusses. During an interview, on 4/4/22 at 3:21 p.m., the DCPS stated even though the patient might decline social services, they will still need to call the patient to explain what the services are because sometimes the patients do not understand what specific services are for. The DCPS stated currently, the nurse doing the initial assessment is the one who assesses for MSW services. A review of the agency's policy and procedure titled, "Psychosocial Services," dated 11/2017, indicated the agency will provide psychosocial services by qualified social workers (MSW, BSW) ...the social worker will contribute to the comprehensive assessment and ongoing update to the comprehensive assessment based on the needs of the patient.

Based on interview and record review the facility failed to provide the bereavement services (emotional, psychosocial, and spiritual support services provided to the family before and after the death of the patient to assist the family in coping with issues related to grief, loss, and adjustment) for up to after one year after the patient's death to surviving family/caregiver member for two of 13 sampled patients, (Patients 1 and 9), This deficient practice has the potential to not provide social, spiritual and cultural supports to the patients/family related to the patient's death. Findings: a. A review of Patient 1's clinical record indicated a start of care (SOC) date of 7/20/2021, with a primary diagnosis of cerebrovascular disease (a group of conditions, diseases, and disorders that affect the blood vessels and blood supply to the brain). A review of Patient 1's "Certification of Terminal Illness" (CTI, terminal illness certifying a prognosis of having 6 months of life or less) indicated Patient 1 had a life expectancy of six months or less if the terminal illness ran its normal course. A review of Patient 1's "Discharge Summary," dated 8/14/2021, indicated Patient 4 passed away of natural causes on 8/14/2021. A review of Patient 1's clinical record indicated there was no documented evidence bereavement services (emotional, psychosocial, and spiritual support services provided to the family before and after the death of the patient to assist the family in coping with issues related to grief, loss, and adjustment) was conducted after and up to one year. During an interview with the Director of Patient Care Services (DPCS) on 9/12/2022, at 3 p.m., DPCS was not able to provide the documented evidence bereavement services was provided after death and up to one year. b. A review of Patient 9's record indicated Start of Care (SOC) was 12/22/2020 and the patient had passed away on 6/7/2021. A review of the Discharge Summary" dated 6/7/2021 indicated Patient 9, who was residing at the housing facility was found on the floor by the facility's administrator. The administrator called 911 and the patient was pronounced dead, and the patient's family was made aware by the Administrator of the housing facility. A review of Patient 9's clinical record indicated there was no documented evidence bereavement services was conducted after and up to one year. During an interview with the Director of Patient Care Services on 9/12/2022, at 3 p.m., she was not able to provide the documented evidence bereavement services was provided after death and up to one year. A review of the facility's policy titled "Bereavement Assessment" revised in April 2017 indicated the facility will provide bereavement services for up to one year after the patient's death to surviving family/caregiver members. b. A review of Patient 8's admission record indicated the patient was admitted to the on 1/8/22, with a primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). Further review of the medical record did not indicate a bereavement assessment was done. c. A review of Patient 9's admission record indicated the patient was admitted on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a chronic lung condition causing difficulty in breathing). Further review of the medical record did, did not indicate a bereavement assessment was done. d. A review of Patient 10's admission record indicated the patient was admitted on 3/2/22 with a primary diagnosis of COPD. Further review of Patient 10's medical record from the agency dated 3/3/22, indicated, "Need for Comprehensive Assessment: Bereavement." Further review of the medical record did not indicate a bereavement assessment was done. During an interview, on 4/4/22 on 2:36 p.m., the MSW stated she did not do bereavement assessments. The MSW stated the Chaplain was responsible for the bereavement assessments. The MSW stated she just assesses quickly, but she did not go into a deep assessment because that is the chaplain's work. e. On 4/9/22, a review of Patient 1's electronic clinical record indicated a start of hospice care date of 11/8/21, with a terminal diagnosis of Atherosclerosis (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) of Coronary Artery Bypass graft (CABG- a surgical procedure used to treat coronary heart disease .It diverts blood diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply's to heart),without Again Pectoris (chest pain or discomfort due to coronary artery disease). A review of the "Initial orders and Plan of Care," dated 11/8/21, indicated the skilled nurse (SN) visit frequency for Patient 1 was once a week and two visits, the social worker to visit once a month to assess, evaluation of communication, coping of patient/caregiver, community resources, intervention of patient and anticipatory grief needs. There was no documented evidence of bereavement assessment for Patient 1. f. On 4/2/22, a review of Patient 2's electronic clinical record, indicated a start of hospice care date 11/6/21, with terminal diagnoses of Heart Failure Unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive. A review of the "Initial orders and Plan of Care" dated 11/6/2021, indicated the SN visit frequency for patient 1 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the social worker to visit once a month to assess, evaluation. The chaplain was instructed to visit once a month to assess and evaluate. There was no documented evidence of bereavement assessment for Patient 2. g. On 4/9/22, a review of Patient 3's electronic clinical record indicated a start of hospice care date of 11/6/21, with a terminal diagnosis of Atherosclerotic Heart Disorder of Native Coronary artery without Again Pectoris (The build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) without chest pain or discomfort due to coronary artery disease). A review of the " Physician's Certification for Hospice Benefit" for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 1's terminal diagnosis was Atherosclerotic Heart Disorder of Native Coronary artery without again pectoris. There was no documented evidence of bereavement assessment for Patient 11. h. On 4/2/22, a review of Patient 11's electronic clinical record, indicated a start of hospice care date 1/11/22, with terminal diagnoses of Heart Failure Unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the "Initial orders and Plan of Care" dated 11/6/2021, indicated the SN visit frequency for patient 1 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the social worker to visit once a month to assess, evaluation. The chaplain was instructed to visit once a month to assess and evaluate. Review of the chaplain's vista notes dated 1/15/22 was blank. During a telephone interview, on 4/4/22 at 2:36 p.m., the hospice agency's Social Worker stated she does not do bereavement assessment the chaplain does. Multiple attempts contact the chaplain was done, however, the chaplain never responded to the calls. The chaplain was unable to be reached for interview. A review of the hospice agency's undated policy and procedure titled, Bereavement Services, indicated a bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice. Information gathered will be incorporated into a plan of care and considered in the bereavement plan of care. A review of the agency's policy and procedure titled, "Psychosocial Services," dated 11/2017, indicated the agency will provide psychosocial services by qualified social workers (MSW, BSW) ...the social worker will contribute to the comprehensive assessment and ongoing update to the comprehensive assessment based on the needs of the patient. A review of the agency's undated policy titled "Bereavement Assessment," indicated on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the bereavement coordinator. The Bereavement Coordinator will review the bereavement risk assessment to determine potential needs of the survivors.

Based on interview and record review the facility failed to provide spiritual counseling in accordance with the patient/family's desires for six out of 11 sample selected patients (Patients 1, 2, 3, 6, 10, and 11). This failure has the potential for the patients/family's spiritual needs to not be met. Findings: a. A review of Patient 6's record indicated the start of care (SOC) date was 11/22/21, with diagnoses of malignant neoplasm of cervix uteri (a type of cancer that occurs in the cells of the cervix [the lower part of the uterus that connects to the vagina]), anemia (low red blood cells in the body), and chronic kidney disease (kidneys are damaged and can't filter blood). Patient 6 was discharged on 12/8/21. A review of the "Initial Orders and plan of care (POC)" dated 11/22/21, indicated the physician and the Registered Nurse (RN) signed electronically on 11/22/22, but there were no signatures for the Medical Social Worker (MSW) and the spiritual care (SC). A review of the "IDG Plan of Care & Review of Comprehensive Assessment" dated 11/22/22 indicated the spiritual counselor services was offered but the patient/family reported that service was not needed. However, the space for signature and the date of the spiritual care was blank. On 4/4/2022, at 9:50 a.m., during a telephone interview with the Family member 1, she stated nobody from the agency had visited Patient 6 for two weeks ever since Patient 6 was admitted to the agency on 11/22/21. Family member 1 stated she had never refused any of the hospice's services the spiritual counseling service. A review of Patient 6's clinical record indicated there was no documented evidence the spiritual counselor had contacted the patient/caregiver and evaluated/assessed the spiritual need of patient/family/ primary caregiver. On 4/5/2022, at 4 p.m., during an interview with the Director of Patient Care Services (DPCS) she stated the agency had a spiritual counselor. however, she was not able to provide the documented evidence the spiritual counselor had attempted to contact the patient/caregiver for explanation about spiritual care service or attended Intradisciplinary Group (IDG) meeting. b. A review of Patient 1's electronic clinical record indicated a start of hospice care date of 11/8/21, with a terminal diagnosis of Atherosclerosis (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) of Coronary Artery Bypass graft (CABG- a surgical procedure used to treat coronary heart disease .It diverts blood diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply's to heart), without Again Pectoris (chest pain or discomfort due to coronary artery disease). A review of the "Initial orders and Plan of Care," dated 11/8/2021, indicated the SN visit frequency for Patient 1 was once a week and two visits, the social worker to visit once a month to assess, evaluation of communication, coping of patient/caregiver, community resources, intervention of patient and anticipatory grief needs. There was no documented evidence of spiritual assessment for Patient 1. c. On 4/2/22, a review of Patient 2's electronic clinical record, indicated a start of hospice care date 11/6/21, with terminal diagnoses of Heart Failure Unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the "Initial orders and Plan of Care," dated 11/6/2021, indicated the SN visit frequency for Patient 2 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver (cg) response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the social worker to visit once a month to assess, evaluation. The chaplain was instructed to visit once a month to assess and evaluate. There was no documented evidence of spiritual assessment for Patient 2. d. A review of Patient 3's electronic clinical record indicated a start of hospice care date of 11/6/21, with a terminal diagnosis of Atherosclerotic Heart Disorder of Native Coronary artery without Again Pectoris. A review of the " Physician's Certification for Hospice Benefit," for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 3's terminal diagnoses was Atherosclerotic Heart Disorder of Native Coronary artery without again pectoris. There was no documented evidence of spiritual assessment for Patient 3. e. A review of Patient 11's electronic clinical record, indicated a start of hospice care date 1/11/22, with terminal diagnoses of Heart Failure Unspecified. A review of the "Initial orders and Plan of Care," dated 11/6/2021, indicated the SN visit frequency for Patient 11 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with IDT. It instructed the social worker to visit once a month to assess, evaluation. The chaplain was instructed to visit once a month to assess and evaluate. Review of the chaplain's visit notes dated 1/15/22 was blank. There was no documented evidence of spiritual assessment for Patient 11. Multiple attempts contact the chaplain was done, however, the chaplain never responded to the calls. The chaplain was unable to be reached for interview. f. A review of Patient 10's admission record indicated the patient was admitted on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a chronic lung condition causing difficulty in breathing). A review of Patient 10's medical record titled, "Physician Order Details," dated 3/2/22, indicated "SC frequency of visit: initial spiritual assessment within 5 days of SOC; follow up visit once a month if necessary." Further review of the medical record from the agency dated 3/3/22, indicated, "Spiritual Assessment informed Hospice Chaplain to contact in: within 5 days." Continued review of the medical record did not indicate a spiritual assessment was done. During an interview, on 4/5/22 at 12:21 p.m., the Director of Patient Care Services (DPCS) stated the Chaplain should have seen the patient and documented on the medical record. A review of facility's policy titled, "Spiritual Care Counseling Services," with a revised date of 11/2017, indicated as the hospice Chaplain will contribute to the comprehensive assessment and ongoing updates to the comprehensive assessment based on the needs of the patient and family. Spiritual care assessments and counseling will be documented in the patient's clinical records as part of the comprehensive assessment and in the interdisciplinary visit notes, as the plan of care. If the patient and family/caregiver refuse spiritual care services, the medical social worker will document refusal. All referrals, assessments, clinical notes, intervention letters, and phone calls will be documented in the patient's clinical record. The Hospice Chaplain will attend interdisciplinary group meetings. The Chaplain will provide staff support by being available to staff for bereavement support.

Based on interview and record review, the hospice agency failed to ensure certified home health aide (CHHA) services were provided in accordance with the patient's plan of care for two of 11 sample selected patients (Patient 5 and 10). This deficient practice prevented the patients from receiving care/services needed that could result in physical discomfort and negative psychosocial effect. Findings: a. A review of Patient 5's admission record indicated the patient was admitted to the hospice agency on 1/12/2022, with primary diagnosis of Atherosclerotic heart disease (narrowing or hardening of the arteries). A review of the "Initial orders and Plan of Care," dated 1/12/22, indicated the skilled nurse (SN) visit frequency for Patient 5 was once a week and two visits as needed and the CHHA visits were two times per week to provide the personal care. On 4/1/2022, at 11:55 a.m., during a joint home visit with the Administrator and the Director of Patient Care Services (DPCS), Patient 5 was observed lying in a bed, closed eyes, and receiving oxygen at 2 liters per minute via nasal canula (plastic tubing that delivered oxygen through the nose). A review of Patient 5's CHHA visit notes indicated as follows: 1. For the week starting 1/12/22 (Wednesday) and ending 1/15/22 (Saturday) - No CHHA visit 2. For the week starting 1/16/22 (Sunday) and ending 1/22/22 (Saturday) - No CHHA visit. 3. For the week starting 1/23/21(Sunday) and ending 1/29/22 (Saturday) - No CHHA visit. 4. For the week starting 3/20/22(Sunday) and ending 3/26/22 (Saturday) - only one visit on 3/21/2022 (Monday). 5. For the week starting 3/27/21(Sunday) and ending 4/1/22 (Saturday) - No CHHA visit. During an interview with the DPCS, on 4/4/2022 at 3:35 p.m., she was not able to provide the documented evidence the CHHA had visited on above days. The DPCS was not able to provide the documentation to explain the reason for the missed visit. The DPCS stated the CHHA should have visited Patient 5 as indicated in the POC. b. A review of Patient 10's admission record indicated the patient was admitted on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a chronic lung condition causing difficulty in breathing). A review of Patient 10's medical record titled "Initial Orders and Plan of Care, for certification period 3/2/22-5/30/22, indicated CHHA first week one visit, following weeks one visit, light housekeeping as needed (PRN). Further review of the medical record titled, "Physician Order Details,", dated 3/2/22, indicated "HA frequency of visits: once a week to assist patient with personal care and activities of daily living for the entire benefit period of (3/2/22-5/30/22). Continued review of Patient 10's visits, indicated the CHHA visited on 3/13/22. No other visits were documented, no documentation was found to explain the reason for the missed visit. During an interview, on 4/4/22 at 1:23 p.m., the DPCS stated the HA had not been having Intradisciplinary Team (IDT) meetings for a while. The DPCS stated she does not remember when it was the last time. The DPCS stated she knows IDT meetings are supposed to report condition of all patients. During an interview, on 4/5/22 at 12:31 p.m., the DPCS stated all visits should be documented. If not documented, it was not done. A review of the HA's policy and procedure titled, "Plan of Care", dated November 2017, indicated " ...14. Care provided to the patient will be in accordance with the plan of care." A review of the agency's policy and procedure of "Plan of Care," with a revised date of 11/2017 indicated the care provided to the patient would be in accordance with the plan of care. A review of the agency's policy and procedure titled "Miss Visits," with a revised date of 11/2017 indicated if a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If a visit is missed and not rescheduled, the clinician will notify the intradisciplinary group (IDG) and clinical supervisor of the missed visit and reason for missed visit.

Based on interview and record review, the Hospice Agency (HA) failed to ensure a registered nurse (RN) made a supervisory visit for patients receiving home aid services for one of 11 sample selected patient (Patient 10). This deficient practice resulted in the RN not determining if the services met the patient and family needs. Findings: A review of Patient 10's admission record indicated the patient was admitted to the HA on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a chronic lung condition causing difficulty in breathing). A review of Patient 10's medical record titled, "Initial Orders and Plan of Care," for certification period 3/2/22-5/30/22, indicated Certified Home Health Aid (CHHA) first week one visits the following weeks one visit for light housekeeping as needed (PRN). During an interview, on 4/5/22 at 12:21 p.m., the Director of Patient Care Services (DPCS) stated supervisory notes should be done by the RN. If not documented, it was not done. Further review of the medical record titled, "Physician Order Details," dated 3/2/22, indicated "HA frequency of visits: once a week to assist patient with personal care and activities of daily living for the entire benefit period of (3/2/22-5/30/22); RN supervisory visit every 14 days. Continued review of Patient 10's medical record, did not indicate an RN supervisory visit had been made. A review of the HA's policy and procedure titled, "Supervision," dated 11/2017 indicated "A registered nurse ...is available whenever homemaker-hospice aide services are provided. Homemaker-hospice aide services are supervised every fourteen (14) days."

Based on observation, interview and record review, the hospice agency failed to ensure volunteer service program was maintained and was offered /provided to the patients for five of 11 sampled patients (Patient 4, 6, 8, 9, and 10). This deficient practice prevented the patients from receiving benefit from the volunteer program. Findings: a. A review of Patient 4's admission record indicated the patient was admitted to the hospice agency on 3/16/2022, with primary diagnosis of Alzheimer's disease. A review of Patient 4's "Initial orders and Plan of Care" dated 3/16/2022, indicated the SN visit frequency was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention, in collaboration with interdisciplinary team (IDT). The "Initial orders and Plan of Care" indicated, the volunteer was "Declined". However, there was no signature of the physician, indicated in the "Initial orders and Plan of Care". On 4/1/2022, at 10:45 a.m., during a joint home visit with Hospice Aide 1 (HA 1), Patient 4 was observed lying in a bed and Family member 2 was seated next to the Patient. At 11:25 a.m., during an interview with Family member 2, he stated the agency staff did not informed and offered the volunteer service. Family member 2 stated, the volunteer service program was not discussed to the patient and the family and he would like to have a volunteer service. On 4/5/2022, at 3:50 p.m., during a telephone interview with the volunteer coordinator, stated she was the only volunteer of the agency. The volunteer coordinator stated, the volunteer services had been suspended since Covid 19 outbreak, so the volunteer service had not been explained and offered to all the patients/family. On 4/5/2022, at 4 p.m., during an interview with the administrator, she also stated the volunteer service had not been explained and offered due to Covid 19. A review of the agency's policy of "Volunteer Services" revised on the year of 2017 indicated the hospice will provide volunteer services under the direction of a volunteer coordinator and with the assistance of trained volunteers. b. A review of Patient 6's record indicated the start of care date was 11/22/2021, with diagnoses of malignant neoplasm of cervix uteri, anemia, and chronic kidney disease. A review of the IDT Plan of Care & Review of Comprehensive Assessment dated 11/22/2021 (section of Volunteer Report) indicated the "Patient declined due to pandemic". On 4/4/2022, at 9:50 a.m., during a telephone interview with the Family member 1, she stated nobody from the agency had visited Patient 6 for two weeks ever since Patient 6 was admitted to the agency on 11/22/2021. Family member 1 stated she had never refused any of the hospice's services. On 4/5/2022, at 3:50 p.m., during a telephone interview with the volunteer coordinator, she stated she was the only volunteer of the agency. She stated the volunteer service had been suspended since Covid 19 outbreak, so the volunteer service had not been explained and offered to any of the agency's patient since Covid 19 outbreak. A review of the agency's policy of "Volunteer Services" revised on the year of 2017 indicated the hospice will provide volunteer services under the direction of a volunteer coordinator and with the assistance of trained volunteers. c. A review of Patient 8's admission record indicated the patient was admitted to the hospice agency on 1/8/2022, with a primary diagnosis of Alzheimer's disease. A review of Patient 8's "Initial Orders and Plan of Care", for certification period 1/8/22-4/7/22, indicated, "orders for discipline and treatment SN first week one visit, one visits, two visits as needed, for pain and symptom management, no CHHA, no PT/OT/ST, Social Worker yes, and Spiritual Care visit decline." The area on the document titled "volunteer" was not marked. During a home visit on 4/1/22, at 9:05 a.m., with DPCS, Patient 8 was observed walking from the living room to the kitchen. Family member 4, next of kin to Patient 8 was present during the SN visit. Family member 4 stated, volunteer services option was there but " I didn't need it right now". Family member 4 stated she did not get a call from the volunteer, the nurse explained what the service was for. During an interview on 4/1/22. At 9:16 a.m., the DPCS stated "wasn't there a hold on volunteer services?". The DPCS stated she was the one who explained all the services available to the patients. A review of Patient 8's medical record did not indicate volunteer coordinator notes or records. A review of the Hospice Agency's policy and procedures titled, "Volunteer Services", dated November 2017, indicated " ...2. The volunteer coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver, in accordance with the plan of care. 3. Volunteers will document their activities on volunteer activity/clinical notes and submit this documentation for the patient's clinical records". d.A review of Patient 9's admission record indicated the patient was admitted to the hospice agency on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 9's "Initial Orders and Plan of Care," for certification period 2/13/22-5/13/22, indicated, "orders for discipline and treatment SN first week, one visits and two visits as needed for pain and symptom management, CHHA no, PT PT/OT/ST no, Social Worker yes, Spiritual Care visit decline, volunteer decline. During a home visit on 4/1/22, at 8:40 a.m., with DPCS, Patient 9 was observed greeting the surveyor and DPCS at the front door. Family member 4, next of kin to Patient 9, was present during the SN visit. During an interview on 4/1/22, at 9:05 a.m., Family member 4 stated volunteer services option was there but " I didn't need it right now". Family member 4 stated she did not get a call from the volunteer, the nurse explained what the service was for. During an interview on 4/1/22. At 9:16 a.m., the DPCS stated "wasn't there a hold on volunteer services?". The DPCS stated she was the one who explained all the services available to the patients. A review of Patient 9's medical record did not indicate volunteer coordinator notes or records. e. A review of Patient 10's admission record indicated the patient was admitted to the hospice agency on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 10's "Initial Orders and Plan of Care, for certification period 3/2/22-5/30/22, indicated, "orders for discipline and treatment SN first week one visits and two visits as needed for pain and symptom management, CHHA yes, PT PT/OT/ST no, Social Worker yes, Spiritual Care visit yes, volunteer decline. During an interview on 4/4/22, at 1:52 p.m., the HR stated her duties at the agency included helping with the human resources and volunteering. HR stated she had not done any patient visits due to COVID 19. HR stated she called patients to see if they needed help. HR stated she documented her visits in a notebook, because "we don't have a patient file". A review of the Hospice Agency's policy and procedures titled, "Volunteer Services", dated November 2017, indicated " ...2. The volunteer coordinator will arrange for volunteers to provide volunteer support to patient and family/caregiver, in accordance with the plan of care. 3. Volunteers will document their activities on volunteer activity/clinical notes and submit this documentation for the patient's clinical records".

Based on interview and record review, the hospice agency failed to ensure that the governing body or the Administrator assumed full legal responsibility for the management of the hospice, the provision of all hospice services, continuous quality assessment and performance improvement, and appointed a qualified administrator to run the day to day operation of the hospice. Findings: On 4/5/22, at 10:45 a.m., during an interview with the Administrator/CEO, she stated she has very limited hospice experience and was the first hospice agency as an administrator. The administrator stated the agency did not have interdisciplinary group meeting, and there was no Covid 19/vaccination program or system in place for all the hospice agency staff. The Administrator and the DON, stated the hospice agency did not have governing body or a quality assessment and performance improvement program. Review of the hospice agency's job description of Executive Director/Administrator dated 11/2017, stipulates, "The Executive Director/Administrator is responsible for the overall direction of the day to day operations of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy."

Based on record review and interview, the hospice agency failed to ensure that the governing body or the Administrator assumed full legal responsibility for the management, the provision of all hospice services, continuous quality assessment and performance improvement, and appointed a qualified administrator to run the day to day operation of the hospice. Findings: On 4/5/22, at 10:45 a.m., during an interview with the Administrator/CEO, she stated she has very limited hospice agency experience and that this was the first hospice agency, to assumed the responsibility as an administrator. The Administrator stated the agency had not conducted an interdisciplinary group meeting, there was no Covid 19 vaccination program developed and implemented for all the agency's staff. During a an interview with the Administrator and the DON, they stated the hospice agency did not had governing body and had no quality assessment and performance improvement for the agency. Review of the hospice agency's job description of Executive Director/Administrator dated 11/2017, stipulates, "The Executive Director/Administrator is responsible for the overall direction of the day to day operations of the hospice services. He/she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly, and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines. The Executive Director/Administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy."

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: 1. The hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness for four of 12 sampled patients (Patient 2, 3, 8, and 10). (Refer L 669) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulations for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications for 11 of 13 sampled patients, (Patient 2, 3, 4, 5, 6, 7, 8, 10, 11, 12 and 13) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. There was no documented evidence the Medical Director or other hospice physician had reviewed the clinical information that included the patient's history and physicals, laboratory and imaging data, biopsy results, etc., necessary for intial certification of hospice care and services. These deficient practices resulted in the hospice medical director and/or other hospice physicians certified the patients for hospice care, without documentation of clinical evidence to support the terminal illnes diagnoses, and could result in lack and inappropriate care provided to the patients. Findings: a. A review of Patient 2's clinical record indicated a start of care (SOC) date of 7/20/2021, with a primary diagnosis of cerebrovascular disease (a group of conditions, diseases, and disorders that affect the blood vessels and blood supply to the brain). A review of Patient 2's "Physician Certification for Hospice Benefit" for the first 90-day period from 4/4/2020 to 7/2/2020, indicated Patient 2's terminal diagnosis was cerebrovascular disease, unspecified. The Medical Director (MD) indicated Patient 2 had a life expectancy of six months or less if the terminal illness ran its normal course. There was no documented evidence the hospice's MD communicated with the primary physician to certify Patient 2 had a life expectancy of six months or less if the terminal illness runs its normal course. The space for "Certifying Physician Summary" was left blank. A review of Patient 2's Comprehensive Nursing Assessment, done by the Registered Nurse (RN), dated 4/4/2020, indicated Patient 2 was awake, alert, oriented, had right eye blindness, non-ambulatory, able to transfer from bed to chair, was using a wheelchair, and needed maximum assistance with activities of daily living. Per the Comprehensive Nursing Assessment, Patient 2 had KPS of 40, PPS of 40%, and NYHA (Spell out abbrevation) class IV. The Karnofsky Performance Scale (KPS) is an assessment tool for predicting of length of survival in terminally ill patients. A KPS of 40 indicated Patient 2 was disabled, requiring special care and assistance. The Palliative Performance Score (PPS) is a widely used tool to access a patient's functional performance and to determine progress towards the end of life. A PPS of 40% indicated Patient 2 was unable to do most activities and was mainly in bed. A review of Patient 2's face sheet indicated Patient 2 resided in Residence 1. b. A review of Patient 3's clinical record indicated a start of care (SOC) date of 12/22/2020, with a primary diagnosis of chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's "Physician Certification for Hospice Benefit" for the first 90-day period from 12/22/2020 to 3/21/2021, indicated Patient 2's terminal diagnosis was chronic obstructive pulmonary disease, unspecified. There was no documented evidence the hospice's Medical Director communicated with the primary physician to certify Patient 3 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 3's undated "LCD Hospice Eligibility Determination" (LCD), indicated Patient 3 was qualified to receive hospice services based on: 1. Severe a chronic lung disease a. Disabling dyspnea at rest as evidenced by: i. poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity (e.g. bed to chair existence, fatigue and cough); b. Progression of end-stage pulmonary disease as evidenced by: iv. Increasing physician home visits (prior to hospice admission). 2. Hypoxia (low oxygen in tissues) b. O2 sat less than or equal to 88% determined either by arterial blood gases or O2 saturation monitors (these values may be obtained from recent hospital records). ________Stopped here 9/22/22-Sonia Richard A review of Patient 3's "Emergency Department Note" from Community Hospital of Huntington Park, dated 10/30/2020, indicated Patient 3's O2 saturation was 98%, lungs were clear to auscultation bilaterally, and there were no rales (an abnormal crackling or rattling sound heard upon auscultation of the chest, caused by disease or congestion of the lungs), wheezes (a whistling or rattling sound in the chest, as a result of obstruction in the air passages), or ronchi (a low-pitched wheezing, snoring, or squeaking sound heard during auscultation of the chest of a person with partial airway obstruction). A review of Patient 3's Comprehensive Nursing Assessment, done by the Registered Nurse (RN), dated 12/22/2020, indicated Patient 3 was awake, alert, oriented to place, time, and person, had mild dyspnea with mild exertion. O2 saturation was 93% on room air. The Comprehensive Nursing Assessment indicated Patient 3 was ambulatory with a cane or walker. During a joint home visit with Licensed Vocational Nurse (LVN) 2 on 9/7/2022 at 11 a.m., Patient 3 was observed awake, alert, and oriented. It was observed Patient 3's oxygen saturation was 96% to 97% on room air. Patient 3 denied shortness of breath. A review of Patient 3's face sheet indicated Patient 3 resided in Residence 1. c. A review of Patient 4's clinical record indicated a start of care (SOC) date of 9/22/2021, with a primary diagnosis of heart disease. A review of Patient 4's "Physician Certification for Hospice Benefit" for the first 90-day period from 9/22/2021 to 12/20/2021, indicated Patient 3's terminal diagnosis was heart disease, unspecified. There was no documented evidence the hospice's Medical Director communicated with the primary physician to certify Patient 4 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 4's "LCD Hospice Eligibility Determination" (LCD), dated 9/22/2021, indicated Patient 4 was qualified to receive hospice services based on the "yes" answer provided for "1. Untreatable Condition c. Is patient optimally treated for heart disease with diuretics and vasodilators? 2. Does this CHF (Chronic Heart Failure - a chronic condition in which the heart doesn't pump blood as well as it should) or angina (a condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, caused by an inadequate blood supply to the heart) patient meet the criteria for NYHA (New York Heart Association) Class IV level (Unable to carry on any physical activity without discomfort. Symptoms of heart failure at rest. If any physical activity is undertaken, discomfort increases). A review of Patient 4's undated "Current Treatment/Medication/DME List "indicated Patient 4 was not on any diuretics or vasodilators. A review of Patient 4's Comprehensive Nursing Assessment, done by the RN, dated 9/22/2021, indicated Patient 4 was awake, alert, oriented to place, time, and person, and had no dyspnea at rest. The same document indicated Patient 4 did not have any cough or labored respiration. During an interview with the Medical Director (MD) of the Hospice Agency (HA) on 9/9/2022 at 12:15 p.m., MD stated he was not the attending physician of the HA's patients. MD stated he looked at a patient's history and physical exam (H&P) and laboratory results. MD stated, "We look at all the information we got in the first 90 days." MD stated LCD assessment was done entirely by a Nurse Practitioner (NP) who worked for him. MD stated he relied on the NP's judgment. MD also stated the NP electronically signed the LCD assessment electronically using his signature. During an interview with Director of Patient Care Services (DPCS) on 9/9/2022 at 3:23 p.m., DPCS stated there was no documented evidence that Patient 3 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators, and O2 sat less than or equal to 88%. DPCS also stated there was no documented evidence that Patient 4 had been optimally treated with diuretics and vasodilators or met the criteria for NYHA class IV. On 9/8/2022 at 3:49 p.m., DPCS also stated Residence 1 was an independent living facility. The homeowners of Residence 1 had no medical responsibilities. Individuals who resided there had to be independent, including taking care of themselves and shopping for their own food. During an interview with Case Auditor/Licensed Vocational Nurse (LVN 1) on 9/9/2022 at 1:30 p.m., LVN 1 stated the HA did not have any records on the weight of Patient 2 prior to his admittance to the HA. She stated the MD was the one making the determination they were eligible for hospice. During an interview with the owner of Residence 1 (Homeowner 2) on 9/7/2022 at 4:09 p.m., Homeowner 2 stated Residence 1 was an independent living. Homeowner 2 stated she provided rooms for homeless people who paid her in exchange for a place to stay. During an interview with Licensed Vocational Nurse (LVN) 2 on 9/8/2022 at 12:50 p.m., LVN 2 stated Residence 1 was an independent living facility and there were no caregivers provided. LVN 2 stated, "My patients walk to the grocery store all the time to buy frozen food." d. A review of Patient 5's clinical record indicated, the patient is 46 years old female who started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) vist was once a week and as needed. The Medical Social Worker (MSW) visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. During a joint home visit with RN 1 on 9/7/2022, at 10:20 a.m., Patient 5 was observed walking using a cane from her car (which was parked in front of the house) to her house (back unit of the house). During an interview with RN 1 at the same time, she stated Patient 5 can drive. During an interview with Patient 5 on 9/7/2022, at10:30 a.m., she stated she lives alone at her unit and she could drive her car to the doctor's office, grocery store, and she could go out for eating. She stated she could cook and shower. She stated she had declined the HA service because she could shower herself. When asked whether she had a pulmonary disease, she stated she had "Asthma" not pulmonary disease, and she did not think she would die within 6 months. A review of Patient 5's "Comprehenive Nursing Assessment" dated 12/28/2021 indicated Patient 5 was alert and oriented, had functional limitation of endurance, was ambulatory using a cane, and had steady gait. Patient 5 had mild dyspnea with mild exertion, and requires oxygen at 2 liters per minute as needed. Patient 5 was observed using chest accesory muscle after activity or walking, and the oxygen saturation at room air was 85 percent. The patient took two puffs of her Albuterol HFA 90 mcg oral inhalation, and after few minutes of rest, the patient's oxygen saturation had improved to 90 percent. Patient 5 had dull ache pain on the bilateral lower legs in a scale of 4/10. Diclofenac Sodium 1 % topical 2-4 times per day for pain management, and the pain was managed well ( reasseed pain prior to end the visit and the pain level was 2/10). A review of the form titled, "LCD Hospice Eligibility Determination" (LCD - Local Coverage Determination - an assessment to determine patient's eligibility for hospice services) of "Pulmonary Disease," dated 12/28/2021, indicated the section 1 and 2 should be met. It indicated Patient 5 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, is less than 30 percent of predicted * Increased visits to Emergency Room A review of Patient 5's record indicated there was no documented evidence Patient 5 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity, Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. A review of Patient 5's record indicated there was no documentation supporting the LCD assessment. A review of Patient 5's form titled, "Physician's Certification for Hospice Benefit" (the document that showed a physician certified a patient's eligibility for hospice benefit), from 12/28/2021 to 3/27/2022, indicated, Patient 5's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 5's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". e. A review of Patient 6's clinical record indicated, the patient is 64 years old male who started hospice care on 7/14/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit once per 2 week plus one visit and LVN visit once per week and one visit as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 6's "Comprehenive Nursing Assessment" dated 7/14/2021 indicated Patient 6 was alert and oriented, used a cane for ambulation, bowel and urinary status was continent. Patient 6 had mild dyspnea with mild exertion, and oxygen saturation was 96 percent. The need of Hospice aide, volunteer and community support was check marked as "None". A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 7/14/2021, indicated the section 1 and 2 should be met. It indicated Patient 6 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Increased visits to Emergency Room *Oxygen saturation less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor A review of Patient 6's record indicated there was no documented evidence Patient 6 was poorly responsive or unresponsive to bronchodilators, Increased visits to Emergency Room, and the oxygen saturation rate was less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 6's record indicated there was no documentation supporting the LCD assessment. A review of Patient 6's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 6's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 5 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 6's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". f. A review of Patient 7's clinical record indicated, the patient is 60 years old male who started hospice care on 2/8/22, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicatedthe Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated Registered Nurse (RN) visit two times per 2 weeks plus one visit as needed and LVN visit once per week and as needed. The services of MSW, chaplain, HA, volunteer visit were not indicated. A review of Patient 7's "Comprehenive Nursing Assessment" dated 2/28/2022 indicated Patient 7 was alert and oriented, used a cane for ambulation. Patient 7 had mild dyspnea with mild exertion, and oxygen saturation was 97 percent. It indicated "No" for the question of whether the patient was uncomfortable because of pain. The need of Hospice aide, was check marked as "None". The need for the Volunteer or community support was blank. The nurse's narrative indicated Patient 7 was observed with on and off shortness of breath and was on Albuterol 90 mcg/Actuation inhalation Aerosol 90 mcg 1-2 puffs inhaler three times a day as needed for shortness of breath/wheezing. Patient 7 had generalized body pain and was on Norco 10 mg-325 mg one tablet by mouth every 6 hours as needed for pain. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 2/28/2022, indicated the section 1 and 2 should be met. It indicated Patient 7 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure *Hypoxemia at rest on room air, as evidenced by pO2 less than or equal to 55 mililimeter Mercury (mmHg). A review of Patient 7's record indicated there was no documented evidence Patient 7 was poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, Hypoxemia (an abnormally low concentration of oxygen in the blood) at rest on room air, as evidenced by pO2 (partial pressure of oxygen - a measure of the tension or pressure of oxygen dissolved in the blood - If a pO2 level is lower than 80 mmHg, it means that a person is not getting enough oxygen) less than or equal to 55 mililimeter mercury (mmHg). A review of Patient 7's record indicated there was no documentation supporting the LCD assessment. A review of Patient 7's form titled, "Physician's Certification for Hospice Benefit" from 7/14/2021 to 10/11/2021, indicated, Patient 7's terminal diagnoses was COPD. It was indicated in the section of "Certifying Physician Summary" that Patient 7 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 7's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". g. A review of Patient 8's clinical record indicated, the patient is 44 years old male who started hospice care on 1/21/22, with a terminal diagnosis of COPD. It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 8/15/2022 indicated the RN visits for initial assessment, supervisory visit, and ongoing comprehensive assessment, reassessment, recertification and as needed. The Skilled Nurse (SN) visit once a week and onece per week as needed. The MSW was to visit within 5 days from the SOC, certification, and as needed. The HA service and the volunteer services were offered and declined. A review of Patient 8's "Comprehenive Nursing Assessment" dated 1/21/2022 indicated Patient 8 was alert and oriented, needed stand by assist for ambulation, Patient 8 had mild dyspnea with mild exertion, and oxygen saturation was 92 percent. Patient 8 was continent in bowel and bladder. The need of Hospice aide, and the need of community support were check marked as "None". The need for the Volunteer was check marked for errands. The nurse's narrative indicated Patient 8 was 43 years old male with last hospitalization on 9/18/2021 to 9/21/2021 for evaluation and treatment of left lower extremity torn ligament. According to the patient, his condition had progressively deteriorated in the past few months, evidence of dyspnea with activity and even at rest. Upon assessment, the patient was sitting in a chair and had a pain level to be 8/10. The patient was placed with medication of norco 10/325 mg one tabletorally every 6 hours as needed for moderate to severe pain and Tylenol 500 mg every 6 hours for breakthrough pain. At the end of the visit and assessment, the patient was noted relaxed without any discomfort, no shortness of breath, and the pain level was 0/10. A review of the form titled, "LCD Hospice Eligibility Determination"of "Pulmonary Disease," dated 1/21/2022, indicated the section 1 and 2 should be met. It indicated Patient 8 was assessed as "yes" in the section 1 and 2 as follows: * Poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough) * Respiratory failure * Oxygen saturation less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documented evidence Patient 8 was poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity (e.g bed to chair existence, fatigue and cough), respiratory failure, Oxygen saturation less than or eual to 88 percent determined either by arterial blood gases or oxygen saturation monitor. A review of Patient 8's record indicated there was no documentation supporting the LCD assessment. A review of Patient 8's form titled, "Physician's Certification for Hospice Benefit" from 1/21/2022 to 4/20/2022, indicated, Patient 8's terminal diagnoses was COPD. It was indicated in the physician's narrative that Patient 8 no longer wants to continue aggressive treatment and stated he wanted comfort measures only. It was indicated in the section of "Certifying Physician Summary" that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 6's record indicated there was no documentation supporting the physician's "Certifying Physician Summary". Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". During an interview with the Director of Patient Care Services (DPCS) on 9/8/2022, at 4:15 p.m., she stated she was not able to find the documented evidence Patient 5, 6, 7, 8, 9, were poorly responsive or unresponsive to bronchodilators, resulting decreased functional capacity, Forced Expiratory Volume in one Second (FEV1) after bronchodilator, was less than 30 percent of predicted, or had Increased visits to Emergency Room. Also, there was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patients' primary physicians that Patient 5, 6, 7, 8, 9 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". On 9/9/2022 at 12:15 p.m., a telephone interview was conducted with the Medical Director of the agency. When asked whether he had his primary patient at the agency, he stated he had a lot of patients and he was not sure/recall. And then, he stated he was not a primary physician for all of the agency's patients. He stated he decides eligibility of hospice care based on signs/symptoms, diagnoses (including history and Physical, labs), ADLs, stability, bed bound status and frequency of hospitalization, and LCD assessment. He stated the Nurse Practitioner (NP) who had been working for him was supposed to review all the assessments including the History and Physical. He stated he had not actually reviewed the patients' History and Physical, and LCD Assessment. Instead, he relied on NP's judgement. When informed that there was no documentation supporting the LCD assessment and the patient's diagnoses, the medical director stated he did not know that. He stated NP 1, who had been working for him for 4-5 months, had been signed his signature electronically in the "Physician's Certification for Hospice Benefit" behalf of him. He stated he had another NP worked for him before NP 1, and he always had a NP worked for him. He stated he did not have any supportive documentation for the hospice eligibility assessment, and had not communicated with the patients' attending physician. He stated he should have overseen things like eligibility of patients for the hospice service. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). A review of the agency's undated Policy and Procedure titled "Certification of Terminal Illness" indicated the clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. According to the LCD, the physician must briefly synthesize the clinical information supporting the terminal diagnosis, and attest that they composed the narrative after reviewing the clinical information and where applicable, examining the patient. A review of the agency's job description summary titled "Hospice Medical Director" revised April 2017 indicated the duties and responsibilities of the Medical Director will include, but not limited to, the following: * Reviewing patients'medical eligibility for hospice services, in accordance with the dhospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness * Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. * Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. *Providing written certification of the terminal illness for all subsequent benefit periods. Based on observation, interview, and record review, the hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications of 9 of 11 sample patients, (Patient 1, 2, 4, 5, 7, 8, 9, 10, and 11) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The agency failed to; Ensure that there was a physician's signature and documentation of clinical information that included patient's history and physicals, laboratory and imaging data, biopsy results, etc., necessary for intial certification of hospice care and services. . These deficient practices resulted in the hospice medical director and/or the hospice attending physicians certified the patients for hospice care, without documentation of clinical evidence to support the terminal illnes diagnoses, and could result to lack and inappropriate care provided to the patients. Findings: On March 31, 2022, an unannounced complaint validation visit was made to the hospice agency who recently moved to Ventura, CA. a. A review of Patient 1's electronic clinical record indicated, the patient started hospice care on 11/8/21, with a terminal diagnosis of Atherosclerosis (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) of Coronary Artery Bypass graft (CABG, a surgical procedure used to treat coronary heart disease, that diverts blood diverting blood around narrowed or clogged parts of the major arteries, to improve blood flow and oxygen supply's to heart),without Again Pectoris ( chest pain or discomfort due to coronary artery disease). A review of Patient 1's "Physician's Certification for Hospice Benefit" for the first 90- day period from 11/8/2021 to 2/5/2022, indicated, Patient 1's terminal diagnoses was Atherosclerosis of Coronary Artery Bypass Graft(S) without Again Pectoris". There was no documented evidence that the hospice medical director or the hospice attending physician communicated, with the patient's primary physician that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course". A review of Patient 1's "initial Nursing Assessment visit" by the RN, dated 11/8/2021, indicated, Patient 1 was forgetful, functional limitation of endurance, ambulatory with the use of a cane, incontinent of bowel/bladder, requires oxygen at 2 Liters per minute (LPM) as needed, with activities up as tolerated/ independent in her home, The assessment indicated, the patient has pain in both knees with a pain scale between 5 to 10, was relieved by oxycodone 15 milligrams (mg., unit of measurements) 1 tablet orally four times a day, with immeninence of death (actively dying) within 72 hours. A review of Patient 1's "Initial orders and Plan of Care" dated 11/8/2021, indicated, the SN visit frequency for Patient 1 was once a week and two visits as needed for symptom management, oxygen at 2 LPM, as needed and for the SN to check the patient's oxygen saturation, PRN for shortness of breath (SOB). The patient's plan of care indicated, to call the physician, if the patient has oxygen saturation of less than 88%, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the Certified Hospice Health Aide to visit once a week for socialization, personal care and light housekeeping as needed. Continued review of the Initial orders and plan of care, indicated an instruction for the Social worker, to visit once a month to assess, evaluation of communication, coping of patient/caregiver,community resources intervention of patient and anticipatory grief needs. A review of Patient 1's " Summary/Plan/Support Diagnosis" indicated, Patient 1 was admitted to hospice under routine level of care for comfort, pain management and symptom management for the first period of 11/8/21 to 2/5/22. The document indicated, that due to patient's poor prognosis and worsening co-morbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have opted that services of hospice comfort care, pain management and symptom management only. It indicated Patient 1 was eating 50-60% less of meals, the patient appeared generally weak and tired, the patient required maximum assistance with activities of daily living care. The document indicated, Patient 1 was able to ambulate with short distances, 5-10 steps with assuasive device. The "Summary Plan/Support Diagnosis" has no signature of the agency's attending physician. On 4/1/2022, at 11:00 a.m., during a joint home visit with Director of Patient Care services (DPCS), to the patient's home, Patient 1 was observed alert, oriented and was ambulating without difficulty. On 4/1/2022 at 11:25 a.m., during an interview with Patient 1, stated she walked five blocks or more with her walker and dog. Patient 1 stated the agency staff did not inform and offer the volunteer or spiritual service . Patient 1 stated, she had never met the hospice agency's physician. Patient 1 stated, she had been going to her primary physician for a routine visit. During an interview, Patient 1, stated she was not informed of the hospice criteria having less than six months to live, Patient 1 stated, "Oh my God!" and the patient stated was not informed about hospice services. Patient 1 stated, she has no terminal illeness and was not informed by any physician, that she has 6 months or less to live. On 4/1/2022 at 12:30 p.m., received a phone call from Patient 1, stated that she read the hospice agency's folder and she was not told by any staff about hospice nor does she agree with the service. Patient 1 stated, she wanted to be discharge from the hospice agency. On 4/12/2022 during interview with the DPCS in the conference room of the hospice agency, she could not provide documented evidence the agency informed Patient 1 of her rights, and if the patient was provided, a written information of the patient's rights before admission to the hospice. b. On 3/3/22, a complaint investigation was initiated due to allegations Patient 2 was diagnosed with Schizoaffective disorder, (a mental health disorder that is marked by a combination of schizophrenia symptoms, such a hallucinations(an experience involving the apparent perception of something not present) or delusions (fixed, false beliefs that conflict with reality), and mood disorder symptoms ,such as depression (a mood disorder that causes a persistent feeling of sadness and loss of interest.), or mania (a condition in which you have a period of excitement manifested by mental and physical hyperactivity, disorganization of behavior, and elevation of mood.), and was approached by the hospice agency, signed up for hospice services even though the patient was not at the end of life and that the client was given medication he does not need without being evaluated by the hospice physician. A review of Patient 2's electronic clinical record, indicated, the patient's start of hospice care was 11/6/2021, with terminal diagnoses of heart failure nnspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet the body needs). A review of Patient 2's "Physician's Certification Hospice Benefit '' for for the 1st 90 -day period, from 11/6/21 to 2/3/22, indicated Patient 2's terminal diagnose was heart failure, unspecified. There was no documented evidence the hospice attending physician communicated with the patient's primary physician, to certify that Patient 2 had a life expectancy of 6 months or less, if the terminal illness runs it normal course. A review of the initial Nursing Assessment by RN dated 11/6/21, indicated Patient 2 "was oriented, depressed, anxiety, has functional limitation of endurance and ambulating,, fatigues easily and with imminence of death within 72 hours." A review of Patient 2's "Initial orders and Plan of Care" dated 11/8/2021, indicated the SN visit frequency for Patient 1 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the Social worker to visit once a month to assess, evaluation of communication, coping of patient/caregiver,community resources, intervention of patient and anticipatory grief needs. The chaplain was instructed to visit once a month to assess and evaluate. It also indicated that volunteer services was "Declined". The admission orders, and the initial orders and Plan of Care was completed by the RN and has no signature of the hospice agency physician. On 4/12/2022 at during interview with the DPCS in the conference room of the hospice agency, she was not able to provide documented evidence the agency informed Patient 2 of her rights and did not provid a written information concerning the patient's rights before admission to the hospice. c. On 4/9/2022, a review of Patient's electronic clinical record indicated a start of hospice care date of 11/6/2021, with a terminal diagnosis of atherosclerotic heart disorder of native coronary artery without angina pectoris. A review of Patient " Physician's Certification for Hospice Benefit" for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 1's terminal diagnoses was Atherosclerotic Heart Disorder of Native Coronary artery without again pectoris. k. A review of Patient 11's electronic clinical record, indicated a start of hospice care date 1/11/2022, with terminal diagnoses of heart failure unspecified(a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet the body needs). A review of Patient 11's "Physician's Certification Hospice Benefit '' for the first 90 -day period, from 1/11/22 to 2/3/22, indicated Patient 11's terminal diagnosis was heart failure, unspecified. The "physician's narrative" indicated, "due to patients' poor prognosis and worsening co-morbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only." There has no documented evidence, the hospice medical director or the hospice attending physician communicated with the patient's primary physician, to certify, that Patient 11 had a life expectancy of 6 months or less if the terminal illness runs its normal course. A review of Patient 11's initial "Nursing Assessment" visit by RN 2 dated 11/6/21, indicated Patient 11 was forgetful, depressed with anxiety, has functional limitation in ambulation and incontinent of bowel/bladder, with musculoskeletal pain/cramps, weakness related to shortness of breath and nerve pain, and fatigues easily. A review of RN 2's under pain assessment indicated, Patient 11 has bilateral ankle/nerve pain , with a pain scale between 3-10, which was treated with Gabepetin 300 mg 3 capsule four times a day and with rest/relaxation and massage A review of Patient 11's "Initial orders and Plan of Care" dated 11/6/2021, indicated the SN visit frequency for Patient 11 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the social worker to visit once a month to assess, evaluation. The document indicated , the RN completed the patient's admission orders and the initial orders and Plan of Care, but there has no signature of the hospice agency's physician. A review of Patient 11's " Summary/Plan/Support Diagnosis, indicated" the patient was admitted to hospice under routine level of care for comfort, pain management and symptom management for the first period of 11/6/21 to 2/3/22, the document indicated that, due to patients' poor prognosis and worsening comorbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only. It indicated Patient 11 was eating 50-60% less meal, appeared generally weak and tired, requires maximum assistance with activities of daily living care and that Patient 11 was able to ambulate with short distances, 5-10 steps with assistive device." Patient 11's "Summary/Plan/Support Diagnosis has no signature of the hopice agency's physician. A review of Skilled Nursing noted completed by the DPCS dated 2/2/2022, under "Reason" for record indicated, the patient was discharged. The form has no documented reason for the patient's discharge. The rest of the SN notes were blank and has no signatures from the DPCS or IDG. During a phone interview on 4/2/2022, at 4:55 p.m.,with Patient 11's caregiver, when asked if she was aware that the patient's on hospice care and has 6 months or less to live. The patient's caregiver stated, the agency's social worker never informed them. The Patient's caregiver stated, that Patient 11 has his own primary physician and the patient was not dying. The patient's caregiver stated, "Take him off hospice now." On 4/5/2022 at 11:02 a.m., during a telephone interview with the hospice agency's Medical Doctor (MD) regarding determining hospice criteria, stated he reviewed the supporting evidence to determine hospice from records from the hospital, records from primary doctors, labs, diagnostic records, reviews the chart, discussed with the RN. The MD stated he see patient on face time and document in the chart. The agency hospice MD stated, he did not have time to document or approve orders and has been behind in signing in the charts . The agency MD stated he thought the staff notifies the patients primary physician. The DPCS and Administrator could not provide all supporting evidence, such as labs, records from the primary doctor, diagnostic results that the MD stated he reviewed for the sample patients, when requested. The Administrator and DPCS were unable to find the documents requested. h. A review of Patient 8's admission record indicated the patient was admitted to the HA on 1/8/22, with a primary diagnosis of Alzheimer's disease. A review of Patient 8's medical record titled, "Certification of Terminal illness", dated 1/8/22, indicated "Hospice physician verbal certification the following statement has been read and agreed to by the Hospice Physician:" no entries indicated on the form and was left blank. "Attending Physician Verbal certification, the following statement has been read and agreed to by the Attending Physician: ", was left blank. "Attending Physician Written Certification", has no attending physician signature. "Hospice Physician Written Certification", has no hospice physician written certification and signature. i.A review of Patient 9's admission record indicated the patient was admitted to the HA on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 9's medical record titled, "Certification of Terminal illness", dated 2/13/22, indicated "Hospice physician verbal certification the following statement has been read and agreed to by the Hospice Physician:" has no entries and was left blank. "Attending Physician Verbal certification, the following statement has been read and agreed to by the Attending Physician: ", has no entries and was left blank . "Attending Physician Written Certification", has no attending physician signature observed. "Hospice Physician Written Certification", no hospice physician written certification and has no signature. j. A review of Patient 10's admission record indicated the patient was admitted to the HA on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 10's medical record titled, "Certification of Terminal illness", dated 3/2/22, indicated "Hospice physician verbal certification the following statement has been read and agreed to by the Hospice Physician:" no entries and was left blank. "Attending Physician Verbal certification, the following statement has been read and agreed to by the Attending Physician: ", has no entries and was left blank. "Attending Physician Written Certification", no attending physician signature observed. "Hospice Physician Written Certification", has no hospice physician written certification and has no signature. During an interview on 4/5/22, at 11:02 a.m., the MD stated he determined hospice criteria by reviewing the charts, discussion with the registered nurse, and see patients through face time (using an electronic device to see the patient virtually). The MD stated the documentation was in the chart. When the surveyor informed the MD documents could not be located in the patients' records, the MD stated he had not had time to document. The MD stated he had to update the notes. A review of the HA's document titled, "Professional Services Agreement Medical Director", dated 8/16/21, indicated " ...Medical Director is responsible for the submission to...of documentation of services provided as appropriate ...E. Medical Director will review and sign initial hospice certifications of terminal illness, and recertifications as indicated. F. Medical Director will review necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician".

Based on observation, interview, and record review, the hospice agency failed to ensure the medical director and/or physician designee conducted accurate recertifications of terminal illness for continued hospice care and services, for 3 of 11 sample patients (Patient 1, 2, and 3) by failing to; Ensure that Patient 1, 2, and 3, recertification has physician's documentation of clinical information (including current history and physician's, laboratory and imaging data biopsy results, etc), conducted a face to face assessment of patient and has the agency's physician's signature to support diagnoses of terminal illnesses in order to determine continuous hospice care and services. This deficient practice resulted in the hospice medical director and/or the hospice attending physician recertified the patients to continue the hospice services, with inaccurate terminal diagnoses and lack of documentation of clinical evidence to support the diagnoses, that could result to lack and inappropriate care and services. Findings: a. A review of Patient 1's electronic clinical record indicated a start of hospice care date of 11/8/21, with a terminal diagnosis of atherosclerosis (the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) of Coronary Artery Bypass graft (CABG, a surgical procedure used to treat coronary heart disease, that diverts the blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply's to heart), without angina pectoris (chest pain or discomfort due to coronary artery disease). A review of Patient 1's "Physician's Certification for Hospice Benefit" for the first 90- day period from 11/8/2021 to 2/5/2022, indicated, Patient 1's terminal diagnoses was atherosclerosis of Coronary Artery Bypass Graft(S) without Again Pectoris". The document has no documented evidence, that the hospice medical director or the hospice attending physician, communicated with the patient's primary physician, to certify that Patient 1 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course." A review of Patient 1's medical record did not indicate a documentation of the patient's recertification for hospice benefits. There has no documented information indicated, the agency's physician reviewed and verified the patient clinical information for continuance of hospice care and services. A review of Patient 1's "Initial orders and Plan of Care" dated 11/8/2021, indicated, the SN visit frequency for Patient 1 was once a week and two visits as needed for symptom management, A review of Patient 1's " Summary/Plan/Support Diagnosis, indicated" Patient was admitted to hospice under routine level of care for comfort, pain management and symptom management for the 1st period of 11/8/22 to 2/5/22,. The document indicated, due to patients's poor prognosis and worsening co-morbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted that services of hospice comfort care, pain management and symptom management only. The patient's "Summary/Plan/Support Diagnosis" has no signature of the agency's physician, that would indicate that the physicain conducted recertification assessment. On 4/1/2022, at 11:00 a.m., during a joint home visit with Director of Patient Care services (DPCS), to the patients home, Patient 1 was observed alert, oriented and ambulating without difficulty. On 4/1/2022 at 11:25 a.m., during an interview with Patient 1 stated, she walked five blocks or more with her walker and dog. Patient 1 stated she has never met the hospice MD and she visits her primary physician. Patient 1 stated ,Oh my God! and stated, she was not informed about hospice service and she has no terminal illness nor has she been told she has 6 months or less to live. On 4/1/22, at 12:30 p.m., the surveyor received a phone call from Patient 1 stated, she just read the hospice agency's folder and she was not told by any staff about hospice services and would not agree with the service. Patient 1 informed the surveyor she wants to be discharged from the hospice agency. On 4/12/22 at 10:40 a.m., during interview with the DPCS in the conference room of the hospice agency, she has not able to provide documented evidence the agency informed Patient 1 of her rights or provided written information on the patient's rights before admission to the hospice. b. A review of Patient 2's electronic clinical record, indicated a start of hospice care date 11/6/21, with terminal diagnoses of heart failure unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet the body needs). A review of Patient 2's "Physician's Certification Hospice Benefit '' for for the first 90 -day period, from 11/6/21 to 2/3/22, indicated Patient 2's terminal diagnosis was heart failure, unspecified. There has no documented evidence the hospice attending physician communicated with the primary physician, to certify that Patient 2 had a life expectancy of 6 months or less, if the terminal illness runs it normal course. A review of Patient 2's medical record did not indicate a documentation of the patient's recertification for hospice benefits. There has no documented information indicated, the agency's physician reviewed and verified the patient clinical information for continuance of hospice care and services after the end of the inital certification on 2/3/22. On 4/12/22 at 10:40 a.m., during interview with the DPCS in the conference room of the hospice agency, she was unable to provide documented evidence the agency informed Patient 1 of her rights or provided written information concerning those rights before admission to the hospice. c. On 4/9/22, a review of Patient 3's electronic clinical record indicated a start of hospice care date of 11/6/21, with a terminal diagnosis of atherosclerotic heart disorder of native coronary artery without angina pectoris. A review of the " Physician's Certification for Hospice Benefit" for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 1's terminal diagnoses was Atherosclerotic Heart Disorder of Native Coronary artery without again pectoris. A review of Patient 3's medical record did not indicate a documentation of the patient's recertification for hospice benefits. There has no documented information indicated, the agency's physician reviewed and verified the patient clinical information for continuance of hospice care and services after the end of the inital certification on 2/3/2022. On 4/5/22 at 11:02 a.m., during a telephone interview with the hospice agency's Medical Doctor (MD) regarding determining hospice criteria, he stated he reviewed the supporting evidence from records from the hospital, records from primary doctors, labs, diagnostic records, to determine hospice care. MD stated he reviewed the chart, discussed with the RN, and document in the chart. MD stated he has not approve orders, documented, and sign the patient's medical record, because he has no time, and has been behind. MD stated he thought the staff notifies the patients primary physician. On 4/12/22 at 10:40 a.m., requested the DPCS and Administrator to provide all supporting evidence, such as labs, records from the primary doctor, diagnostic results that the MD stated he reviewed for the sample patients . The DPCS and the Administrator stated, they were unable to find the documents requested.

Based on observation, interview and record review, the hospice agency failed to ensure, the agency's medical director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, review, and verify patient clinical information necessary for initial certification and recertification of terminal illness. This deficient practice resulted in the hospice medical director and/or the hospice attending physician certifying patients with inaccurate terminal diagnoses, without documentation of clinical evidence to support the diagnoses, as required by the Federal regulations. Findings: a. A review of Patient 3's Personal Information Sheet (Face Sheet) indicated a start of care (SOC) date of 7/19/22, with a primary diagnosis of Hypertensive heart disease (high blood pressure) without heart failure. There is no other diagnosis listed on the Face Sheet. A review of Patient 3's Comprehensive Nursing Assessment, dated 7/19/22, under the section "Nature and Condition of Terminal Illness/LCD Eligibilty", indicated that Patient 3's terminal illness of heart disease was reported by the patient, no medical history was used as evidence. It also stated that Patient 3 did not have any ER visits or hospitalizations in the last 12 months and does not need any assistance with walking, toileting, transfers, dressing, feeding, or bathing. A review of Patient 3's Physician's Certification for Hospice Benefit (CIT), for the first 90 day period from 7/19/22-10/16/22, indicated that the medical doctor (MD) certified that Patient 3 has a life expectancy of six months or less, if the illness runs its normal course. There are three options that the MD can check off to identify what the certification is based on ... 1. Medical history, record and patient status 2. Team Assessment 3. Face to face encounter None of the options are checked off and there is no physician narrative note indicating that a face to face visit was conducted. A review of Patient 3's Local Coverage Determination (LCD)Hospice Eligibility Determination sheet, (undated), indicated that Patient 3 has a history of treatment-resistant symptomatic supraventricular or ventricular arrhythmias (irregular heart rhythms that can cause symptoms such as chest pain, dizziness, pounding heartbeat, lightheadedness, and shortness of breath) and unexplained fainting. Although, there was no documentation found in Patient 3's medical record to support the stated history. b. A review of Patient 2's Face Sheet indicated a SOC of 7/19/22, with a diagnosis of hypertensive heart disease with heart failure (chronic condition where heart does not pump blood as well as it should). A review of Patient 2's Comprehensive Nursing Assessment, dated 7/19/22, under the section "Nature and Condition of Terminal Illness/LCD Eligibilty", indicated that Patient 3's terminal illness of heart disease was reported by the patient and family, no medical history was used as evidence. It also stated that Patient 3 did not have any ER visits or hospitalizations in the last 12 months. Patient 2 needs assistance with walking, toileting, transfers, dressing, feeding, or bathing. A review of Patient 2's Physician's Certification for Hospice Benefit (CIT), for the first 90 day period from 7/19/22-10/16/22, indicated that the medical doctor (MD) certified that Patient 3 has a life expectancy of six months or less, if the illness runs its normal course. There are three options that the MD can check off to identify what the certification is based on ... 1. Medical history, record and patient status 2. Team Assessment 3. Face to face encounter None of the options are checked off and there is no physician narrative note indicating that a face-to-face visit was conducted. A review of Patient 2's Local Coverage Determination (LCD) Hospice Eligibility Determination sheet, (undated), indicated that Patient 2 has a history of of unexplained fainting. Although, there was no documentation found in Patient 3's medical record to support the stated history. h. A review of Patient 8's electronic clinical record indicated a start of hospice care date of 11/17/2020, with a terminal diagnosis of Hypertensive heart disease without heart failure ( a heart condition caused by high blood pressure which causes the heart to work under ncreased pressure.) . A review of Patient 8's "Physician's Certification for Hospice Benefit" for the tenth 60- day recertification period from 7/10/2022 to 9/7/2022, indicated Patient 8's hypertensive heart disease without heart failure. There was no documented evidence the hospice agency's medical director or the hospice attending physician had communicated with the patient's primary physician to certify that Patient 8 had a life expectancy of 6 months or less, "if the terminal illness runs its normal course." A review Patient 8's "initial Nursing Assessment" visit by the RN, dated 11/17/2020, indicated Patient 8 was alert, requires bed/wheelchair bound and requires maximum assistnce , with standing, requires oxygen at 2 liters per minute (LPM) as needed, with activities up as tolerated/ A review of Patient 8's "Initial orders and Plan of Care" dated 11/17/2021, indicated the SN visit frequency was once a week and two visits as needed for symptom management, oxygen at 2 LPM as needed, and for the SN to check oxygen saturation as needed for shortness of breath (SOB), to call MD if oxygen saturation, less than 88% nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). The RN completed the patient's initial orders and Plan of Care, but there has no signature of the agency's physician, that would indicate that the plan of care and initial orders was reviewed by the agency's physician. A review of Patient 8's " LCD Hospice Eligiblility Determination indicated pthat patient 8 has a history of unesplained syncope/fainting. i. . A review of Patient 10's electronic clinical record, indicated a start of hospice care date 7/22/2022, with terminal diagnoses of heart failure unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet body needs). A review of patient 10's "Physician's Certification Hospice Benefit'' for the first 90 -day period, from 7/22/2022 to 10/19/2022, indicated, patient 10's terminal diagnose was atherosclerosis(the build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow). There has no documented evidence the hospice agency's attending physician communicated with the patient's primary physician, to certify that patient 10 had a life expectancy of 6 months or less, "if the terminal illness runs it normal course." A review of patient 10's "initial Nursing Assessment" by RN dated 7/22/2022, indicated patient 10 was oriented x 3 , but forgetful at times, able to do most of her activities of Daily living (ADL) but someone has to be with her at all times, with episodes of chest pain at least twice a week and per daughter patient 10 has lost a lot of weight but how much unknown. A review of patient 10's "Initial orders and Plan of Care" dated 11/17/2021, indicated the SN visit frequency was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). The RN completed Patient 10's admission orders the initial orders and Plan of Care, but has no signature of the agency's physician that would indicate that the agency's physician review and verify the patient clinical information. A review of patient 10's LCD Hospice Eligibility determination indicate patient 10 had a history of unexplained syncope/fainting. On 9/12/22 at 2:02 p.m., during a telephone interview with the hospice agency's Medical Doctor (MD) in the conference room of the hospice agency regarding determining hospice criteria, he stated he reviews the supporting evidence to determine hospice from records from the admitting Registered Nurse (RN). The Hospice agency's MD conducts a face to face visit and based on the documentation from the skilled nurse assessment in the patients chart and his assessment, qualifies the patients for hospice. The hospice agency's MD stated, he has not viewed the hospital, records from primary doctors, labs, diagnostic records, reviews the chart and that maybe they need to incorporate that procedure, before admitting the patients to hospice. The MD stated, he thought the staff notified the patient's primary physician. During an interview and concurrent patient record review with the CFO and DPCS in the hospice agency's conference room on 9/16/2022, at 3:30 p.m., regarding determining hospice criteria, they stated they receive supporting evidence from the hospital or primary physician which consist of the hospital, records from primary doctors, labs, diagnostic records, reviews the chart to ensure the patients meet the hospice criteria. On 9/16/2022 at 3:40 p.m., requested the DPCS and CFO to provide all supporting evidence, such as labs, records from the primary doctor, diagnostic results that the MD stated he reviewed for the sample patients, but the DPCS and the CFO were unable to find the requested documents. A review of the hospice agency's policy and procedure on " Admission Criteria and process revised April 2018, stipulates, " Referral information provide by family/caregiver, health care clinicians from acute care facilities, skilled or intermediate nursing facilities, other agencies, and physician office will assist in the determination of eligibility for admission to the program. If the request for services is not made by the patient's physician, he/she will be consulted prior to the evaluation visit/initiation of services." h. A review of Patient 8's admission record indicated the patient was admitted to the HA on 1/8/22, with a primary diagnosis of Alzheimer's disease. A review of Patient 8's medical record titled "IDT Plan of Care and review of comprehensive assessment", dated 1/11/22, indicate the MD did not sign the document. A review of medical record titled, "Physician Order Details", dated 1/8/22, indicated "Orders type: Admission Order". The physician order did not indicate the MD had signed the orders. i. A review of Patient 9's admission record indicated the patient was admitted to the HA on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 9's medical record titled "IDT Plan of Care and review of comprehensive assessment", dated 2/22/22, did not indicate the MD had signed the document. A review of medical record titled, "Physician Order Details", dated 2/13/22, indicated "Orders type: Admission Order". The physician order did not indicate the MD had signed the orders. j. A review of Patient 10's admission record indicated the patient was admitted to the HA on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 10's medical record titled "IDT Plan of Care and review of comprehensive assessment", dated 3/22/22, did not indicate the MD had signed the document. A review of medical record titled, "Physician Order Details", dated 3/2/22, indicated "Orders type: Admission Order". The physician order did not indicate the MD had signed the orders. During an interview on 4/5/22, at 11:02 a.m., the MD stated he was the Medical Director for the HA. The MD stated the development of the plan of care was based on medical records, discussion with family, knowing their wishes and talking to the patient, if they are able to communicate. The MD stated he had not been communicating with patient's primary physician. When the surveyor asked why the MD's notes were not in the patient record, the MD stated, "Like I said, I am a little behind with my documentation. I haven't been able to do that. I have been really behind in signing all the charts. I have been very busy . I have not had time to review and chart". During an interview on 4/4/22, at 1:20 p.m., the DPCS stated the MD "never goes to see the patient, that is why we need to get another doctor". A review of the HA's document titled, "Professional Services Agreement Medical Director", dated 8/16/21, indicated, " ...G. Medical Director will review the clinical records and/or performing a medical examination to confirm the appropriateness of services. H. Medical Director will assist in the development and implementation of the plan of care that is coordinated with the attending physician. A review of the HA's policy and procedure titled, "Job Descriptions Hospice Medical Director", dated April 2020, indicated, "The hospice Medical Director will have overall responsibility for the medical component of the hospice program ...14. Reviewing patients' medical eligibility for hospice services ...establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing are written certification of terminal illness ...24. Assisting in the development and implementation of the plan of care that is coordinated with the attending physician. 25. Documenting care provided in the patient's clinical record ..."

Based on interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation on Clinical Records was met as follows: 1. The HA failed to ensure the patient's clinical record was complete and accurate for four of 11 sampled patients (Patient 1, 2, 3, and 11) by failing to: a. Ensure that Patient 1's clinical record that included Summary/Plan/Support Diagnosis and Initial orders and Plan of Care had been signed the physician, the supervisory visit notes was completely filled out, and that Patient 1's improved condition was reflected in the patient's clinical record. b. Ensure that the clinical records for Patient 2 and 3 that included the Initial Orders and Plan of Care was signed by physician, and improvement in the patient's condition was reflected in the patient's clincial record. c. Ensure that Patient 11's clinical record that included included the Initial Orders and Plan of Care and Summary/Plan/Support Diagnosis were signed by physician, and improvement in the patient's condition was reflected in the patient's clincial record. This deficient practice resulted in incomplete records and had potential for inability to evalaute the care provided to Patient 1, 2, 3, and 11 (Refer to L 671). 2. The HA failed to ensure the clinical records contained Initial/Comprehensive assessment, bereavement assessment, and clinical notes that were updated and recorded for seven of 11 sampled patients (Patient 4,5,6,7,8,9, and 10). This deficient practice resulted in clinical records that were not updated and had the potential for inability to evaluate the care provided to the patients (Refer to L 672). 3. The HA failed to ensure the clinical records contained the admission orders, plan of care (POC), medication orders that were signed and/or dated by the physician, the interdisciplinary group (IDG) prepared the patient's POC in developing the patient's care plan, and evidence the hospice attending physician communicated with the primary physician, to certify the patients had a life expectancy of six months or less, if the terminal illness runs it normal course for seven of 11 sampled patients (Patient 1,2, 3,8,9,10, and 11, ) These deficient practices resulted in the physician orders that were not signed to provide care or verifying the patients' orders and plan of care, and potential for inability to evaluate care provided to the patients (Refer to L 678). 4. The HA failed to ensure the clinical records were authenticated for three of 11 sampled patients (Patients 8,9, and 10). This deficient practice resulted in patient care records not being validated for the care received (Refer to L 679). 5. The hospice agency (HA) failed ensure that two of 11 sample patients ( Patient 2 and 3) that were discharged from the hospice agency had a discharge summary that included a summary of the patients stay, treatments, symptoms, current plan of care, pain management, patients last physician orders and any other documents .This deficient practice had the potential for not ensuring continuity of care after the patients were discharged (Refer to L 684). The cumulative effects of these systemic problems resulted in the HA's inability to ensure the provision of quality health care in a safe environment.

Based on record review and interview, the hospice agency (HA) failed to ensure the patient's clinical record was complete and accurate for four of 11 sampled patients (Patient 1, 2, 3, and 11) by failing to: a. Ensure that Patient 1's clinical record that included Summary/Plan/Support Diagnosis and Initial orders and Plan of Care had been signed the physician, the supervisory visit notes was completely filled out, and that Patient 1's improved condition was reflected in the patient's clinical record. b. Ensure the clinical record for Patient 2 that included the Initial Orders and Plan of Care was signed by physician, and improvement in the patient's condition was reflected in the patient's clincial record. c. Ensure the clinical record for Patient 3 had the signature of the physician in the admission order, Certification of Terminal Illness, and Initial orders and Plan of Care, and documented evidence in Patient 3's clinical record that Patient 3's condition had improved. d. Ensure Patient 11's clinical record that included the Initial Orders and Plan of Care and Summary/Plan/Support Diagnosis were signed by physician, and improvement in the patient's condition was reflected in the patient's clincial record. This deficient practice resulted in incomplete records and had potential for inability to evaluate the care provided to Patient 1, 2, 3, and 11. Findings: a. A review of Patient 1's electronic clinical record indicated a start of hospice care date of 11/8/21, with a terminal diagnoses of atherosclerosis (a build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) of coronary artery bypass graft (CABG, a surgical procedure used to treat coronary heart disease. It diverts blood diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply's to heart), without angina Pectoris (chest pain or discomfort due to coronary artery disease). A review of Patient 1's Initial Nursing Assessment visit completed by the registered nurse (RN) dated 11/8/2021, indicated Patient 1 was forgetful, functional limitation of endurance, ambulatory with the use of a cane, incontinent of bowel/bladder, required oxygen at two liters per minute (LPM) as needed, with activities as up as tolerated/ independent in her home, had pain in both knees with a pain scale between 5 to 10, which was relieved by oxycodone (medication to treat pain) 15 mg, one tablet orally four times a day, with imminence of death (actively dying) within 72 hours. The last skilled nuring notes in Patient 1's electronic recorded was dated 2/3/22. A review of the supervisory visit notes dated 1/3/22, 1/17/22, and 1/31/22, were left blank. A review of Patient 1's "Initial orders and Plan of Care" dated 11/8/2021, indicated the skilled nurse (SN) visit frequency for Patient 1 was once a week and two visits as needed for symptom management, oxygen at two LPM as needed and for the SN to check oxygen saturation PRN (as needed) for shortness of breath (SOB), call the physician for oygen saturation less than 88%, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/caregiver care plan/intervention in collaboration with interdisciplinary team (IDT). The Certified Hospice Health Aide was to visit once a week for socialization, personal care, and light housekeeping as needed. A review of the Initial orders and Plan of Care indicated the social worker was to visit once a month to assess, evaluation of communication, coping of patient/caregiver, community resources, intervention of patient and anticipatory grief needs. It also stipulated that volunteer, and spiritual care was "Declined." However, the Initial Orders and Plan of Care was completed by the RN, and there was no signature of the physician in the "Initial orders and Plan of Care." A review of Patient 1's "Summary/Plan/Support Diagnosis, indicated" Patient 1 was admitted to hospice under routine level of care for comfort, pain management and symptom management for the first period of 11/8/21 to 2/5/22. Due to the patient's poor prognosis and worsening comorbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only. Patient 1 was eating 50-60% less, appeared generally weak and tired, requires maximum assistance with activities of daily living care and that Patient 1 was able to ambulate with short distances, 5-10 steps with assistive device." There was no signature of the physician. On 4/1/2022, at 11:00 a.m., a joint home visit was conducted with Director of Patient Care services (DPCS), at the patient's home. Patient 1 was observed alert, oriented and ambulating without difficulty. On 4/1/22 at 11:25 a.m., during an interview, Patient 1 stated she walks five blocks or more with her walker and dog. Patient 1 stated the agency staff did not inform and offer the volunteer or spiritual service. When the surveyor explained about the volunteer program, he stated he would like to have volunteer service. Patient 1 stated she has never met the hospice MD and sees her primary physician regular. Patient 1 stated she is not on oxygen and takes pain pills for her back. When the surveyor informed Patient 1 that the hospice criteria was having less than six months to live, Patient 1 stated, "Oh my God!" She stated she was not informed about hospice service, and she is not terminal, nor has she been told she has six months or less to live. On 4/1/22, at 12:30 p.m., the surveyor received a phone call from Patient 1, who stated she just read the hospice agency's folder and she was not told by any staff about hospice, nor did she agree with the service. Patient 1 informed the surveyor she wants to be discharged from the hospice agency. On 4/1/22, at 10:00 a.m., during a concurrent record review and interview with the DPCS in the conference room of the hospice agency, the DPCS stated the agency did not have an IDG meeting to re-evaluate Patient 1's condition. A review of Patient 1's clinical record indicated there was no documented evidence that Patient 1's condition had improved. b. On 4/2/22, a review of Patient 2's electronic clinical record, indicated a start of hospice care date 11/6/21, with terminal diagnosis of heart failure, unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of Patient 2's Initial Nursing Assessment visit by the RN dated 11/6/21, indicated Patient 2 was oriented, depressed, anxiety, hds functional limitation of endurance and ambulation, fatigues easily and with imminence of death within 72 hours. A review of Patient 2's Initial orders and Plan of Care" dated 11/6/2021, indicated the SN visit frequency for Patient 2 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver (cg) response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). The social worker was instructed to visit once a month to assess, evaluation. The chaplain was instructed to visit once a month to assess and evaluate. It also indicated that volunteer services were "Declined." However, the admission orders, the initial orders, and Plan of Care was completed by the RN, and there was no signature of the physician in the admission order or the Initial Orders and Plan of Care. A review of Patient 2's "Summary/Plan/Support Diagnosis, indicated" Patient 2 was admitted to the hospice under routine level of care for comfort, pain management and symptom management for the first period of 11/6/21 to 2/3/22. Due to the patient's poor prognosis and worsening comorbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only. Patient 2 was eating 50-60% less, appeared generally weak and tired, requires maximum assistance with activities of daily living care and that Patient 2 was able to ambulate with short distances, 5-10 steps with assistive device." There was no signature of the physician. There was no documented evidence in Patient 2's clinical record that Patient 2's condition had improved. c. A review of Patient 3's electronic clinical record indicated a start of hospice care date of 11/6/21, with a terminal diagnosis of atherosclerotic heart disorder of native coronary artery without angina pectoris. A review of Patient 3's "Physician's Certification for Hospice Benefit" for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 1's terminal diagnoses was atherosclerotic heart disorder of native coronary artery without angina pectoris. Due to patient's poor prognosis and worsening comorbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only. A review of Patient 3's Iinitial Nursing Assessment visit by the RN, dated 11/6/2021, indicated Patient 1 was forgetful, depressed, with anxiety functional limitation of ambulation and, incontinent of bowel/bladder. A review of Patient 3's "Initial Orders and Plan of Care" dated 11/6/2021, indicated the SN visit frequency for Patient 3 was once a week and two visits as needed for symptom management nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). the Certified Hospice Health Aide was to visit once a week for socialization, personal care, and light housekeeping as needed. A review of the Initial orders and Plan of care instructed the social worker was to visit once a month to assess, evaluation of communication, coping of patient/caregiver, community resources, intervention of patient and anticipatory grief needs. the social worker was to visit once a month to assess, evaluation. However, the admission orders, initial orders, and Plan of Care was completed by the RN, and there was no signature of the physician in the admission order, Certification of Terminal Illness, or the Initial orders and Plan of Care. There was no documented evidence in Patient 3's clinical record that Patient 3's condition had improved. A review of Patient 3's "Summary/Plan/Support Diagnosis, indicated" Patient was admitted to hospice under routine level of care for comfort, pain management and symptom management for the first period of 11/6/21 to 2/3/22. Due to patient's poor prognosis and worsening comorbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only. It also indicated Patient 3 is eating 50-60% less, appeared generally weak and tired, requires maximum assistance with activities of daily living care and that Patient 3 was able to ambulate with short distances, 5-10 steps with assistive device." d. On 4/2/22, a review of Patient 11's electronic clinical record, indicated a start of hospice care date 1/11/22, with terminal diagnoses of Heart Failure Unspecified (a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of the '"Physician's Certification Hospice Benefit '' for the 1st 90 -day period, from 1/11/22 to 2/3/22, indicated Patient 2's terminal diagnosis was Heart Failure, Unspecified. The" physician's narrative" indicated "due to patient's poor prognosis and worsening comorbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only." A review of the initial Nursing Assessment visit by RN 2 dated 11/6/21, indicated Patient 11 was forgetful, depressed with anxiety, has functional limitation of ambulation and incontinent of bowel/bladder, with musculoskeletal pain/cramps, weakness related to shortness of breath and nerve pain, and fatigues easily. A review of RN 2's under pain assessment indicated Patient 11 has bilateral ankle/nerve pain, with a pain scale between 3-10, which is treated with Gabapentin 300 mg 3 capsule four times a day and with rest/relaxation and massage. A review of the "Initial orders and Plan of Care" dated 11/6/2021, indicated the SN visit frequency for Patient 11 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the social worker to visit once a month to assess, evaluation. The chaplain was instructed to visit once a month to assess and evaluate. It also indicated that volunteer services were "Declined." However, admission orders, the initial orders and Plan of Care was completed by the RN and there was no signature of the physician in the admission order or the Initial orders and Plan of Care. A review of patient 11's "Summary/Plan/Support Diagnosis, indicated Patient 11 was admitted to the hospice under routine level of care for comfort, pain management and symptom management for the 1st period of 11/6/21 to 2/3/22. Due to patients' poor prognosis and worsening comorbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only. It also indicated Patient 11 was eating 50-60% less, appeared generally weak and tired, requires maximum assistance with activities of daily living care and that Patient 2 is able to ambulate with short distances, 5-10 steps with assistive device." There was no signature of the physician. A review of Skilled Nursing noted completed by the DPCS dated 2/2/22, underrReason for record indicated discharge. There was no documented reason for discharge on the form The rest of the SN notes were blank with no signatures from the DPCS or IDG. During a telephone interview on 4/2/22, at 4:55 p.m., with Patient 11's caregiver, when asked if she was aware that hospice is for patients with 6 months or less to live, she stated the social worker never informed them of that and Patient 11 has his own primary physician and is not dying. At that time, the PCG state " Take him off hospice now." On 4/5/22 at 11:02 a.m., during a telephone interview with the hospice agency's Medical Doctor (MD) regarding determining hospice criteria, he stated he reviews the supporting evidence to determine hospice from records from the hospital, records from primary doctors, labs, diagnostic records, reviews the chart, discuss it with the RN, see patient on face time and document in the chart. The agency hospice's MD stated he has not had time to document or approve orders and has been behind in signing in the charts. The MD stated he thought the staff notifies the patients primary physician. The DPCS and Administrator were asked to provide all supporting evidence, such as labs, records from the primary doctor, diagnostic results that the MD stated he reviewed for the sample patients. They were unable to find the documents requested. During an interview with the DPCS on 2/12/22, at 2: 20 pm, she stated that form was the end of care summary and that it should have been completed by the IDG, however the agency has not had IDG meeting since she started at the agency on 1/16/2022 and that no discipline was involved in the IDG including the Medical Doctor. There was no documented evidence in Patient 11's clinical record that Patient 11's condition had improved.

Based on interview and record review, the hospice agency (HA) failed to ensure the clinical records contained Initial/Comprehensive assessment, bereavement assessment, and clinical notes that were updated and recorded for seven of 11 sampled patients (Patient 4,5,6,7,8,9, and 10). This deficient practice resulted in clinical records that were not updated and had the potential for inability to evaluate the care provided to the patients. Findings: a. A review of Patient 4's admission record indicated the patient was admitted to the hospice agency on 3/16/2022, with primary diagnosis of Alzheimer's disease (chronic neurodegenerative disease that starts slowly and worsens over time). A review of Patient 4's "IDG Plan of Care & Review of Comprehensive Assessment" dated 3/22/2022 indicated the medical social worker (MSW) evaluated and assessed needs of the patient, family and primary caregiver. It indicated spiritual services were offered but the patient/family reported that service was not needed. It also indicated in the "Volunteer Report" section that Patient 4 declined due to COVID-19 ((Coronavirus 19 disease, a severe respiratory illness caused by virus and spread from person to person) pandemic. A review of Patient 4's clinical record indicated there was no documented evidence the MSW, the spiritual counselor (SC), the volunteer coordinator had performed the Initial/Comprehensive assessment. Also, there was no documentation of bereavement assessment. b. A review of Patient 5's admission record indicated the patient was admitted to the hospice agency on 1/12/2022, with primary diagnosis of atherosclerotic heart disease. A review of Patient 5's "IDG Plan of Care & Review of Comprehensive Assessment" dated 1/25/2022, 2/8/2022, 2/22/2022, 3/8/2022, 3/22/2022 indicated the MSW evaluated and assessd the needs of the patient, family and primary caregiver. They also indicated the spiritual services were offered but the patient/family reported that service was not needed. It also indicated in the "Volunteer Report" section that Patient 5 declined due to pandemic. A review of the Patient 5's clinical record indicated there was no documented evidence the MSW, SC, volunteer coordinator had performed the Initial/comprehensive assessment. Also, there was no documentation of bereavement assessment. c. A review of Patient 6's record indicated the start of care date was 11/22/2021, with diagnoses of malignant neoplasm of cervix uteri, anemia, and chronic kidney disease. Patient 6 was discharged on 12/8/2021. A review of Patient 6's "IDG Plan of Care & Review of Comprehensive Assessment" dated 11/22/2022 indicated the MSW services were offered but not needed at "this time" The Spiritual counselor services were offered but the patient/family reported that service was not needed. It also indicated in the "Volunteer Report" section that Patient declined due to pandemic. A review of Patient 6's clinical record indicated there was no documented evidence the MSW, SC, the volunteer coordinator had performed the comprehensive assessment. Also, there was no documentation of bereavement assessment. d. A review of Patient 7's record indicated the start of care date was 11/18/2021, with diagnosis of Stage III chronic kidney disease. A review of Patient 7's "IDG Plan of Care & Review of Comprehensive Assessment" dated 11/30/2021, 12/14/2021, 12/28/2021, 1/11/2022, 1/25/2022, 2/8/2022, indicated the spaces for the spiritual care report and the MSW report were blank. The "IDG Plan of Care & Review of Comprehensive Assessment" dated 2/22/2022, 3/8/2022, 3/22/2022, indicated the MSW service and the spiritual care service were offered, but the patient/family reported that services were not needed at "this time". It also indicated in the "Volunteer Report" section that Patient declined due to pandemic. A review of the Patient 7's clinical record indicated there was no documented evidence the MSW, SC, the volunteer coordinator had performed the Initial/comprehensive assessment. Also, there was no documentation of bereavement assessment. On 4/4/2022, at 2:35 p.m., during a telephone interview with the MSW, she stated when the agency nurse informs her regarding the need of social services, she calls the patient to make a scheduled appointment, and goes to see the patient in person to perform psychosocial assessment. The MSW stated she was supposed to document the psychosocial assessment on the computer in the psychosocial space. She stated the name of the signature page is done by the computer when she log in, and that meant the documentation was done by her. On 4/5/2022, at 3:50 p.m., during a telephone interview with the volunteer coordinator, she stated she was the only volunteer of the agency. She stated the volunteer service had been suspended since Covid-19 outbreak, so the volunteer service had not been assessed to any of the agency's patients since Covid-19 outbreak. On 4/5/2022, at 4 p.m., during an interview with the Director of Patient Care Services (DPCS) she was not able to provide the documented evidence the MSW, SC had performed the initial/comprehensive assessment. Also, she was not able to locate the bereavement assessment for Patient 4, 5, 6, and 7. A review of the agency's policy and procedure titled, "The Plan of Care" revised in November 2017 indicated the plan of care would be based on the initial, comprehensive and ongoing comprehensive assessments performed by members of the interdisciplinary group and would be reviewed on a regular basis. e. A review of Patient 8's admission record indicated the patient was admitted to the HA on 1/8/22, with a primary diagnosis of Alzheimer's disease. A review of Patient 8's "Initial Orders and Plan of Care," for certification period 1/8/22-4/7/22, indicated "orders for discipline and treatment skilled nurse (SN) visit first week one (1) visits, two (2) PRN (as needed) visits for pain and symptom management. Further review of the record indicated Patient 8 was scheduled to be visited by the nurse on 3/26/22 and 4/1/22. There were no clinical notes in Patient 8's record of these visits. f. A review of Patient 9's admission record indicated the patient was admitted to the HA on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 9's medical record titled, "Initial Orders and Plan of Care, for certification period 2/13/22-5/13/22, indicated "orders for discipline and treatment SN 1st week 1 visits and 2 PRN visits for pain and symptom management. Further review of the record indicated Patient 9 was scheduled to be visited by the nurse on 3/24/22 and 3/31/22. There were no clinical notes in Patient 9's record of these visits. g. A review of Patient 10's admission record indicated the patient was admitted to the HA on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. A review of Patient 10's medical record titled, "Initial Orders and Plan of Care, for certification period 3/2/22-5/30/22, indicated "orders for discipline and treatment SN 1st week 1 visits and 2 PRN visits for pain and symptom management. Further review of the record indicated Patient 10 was scheduled to be visited by the nurse on 3/16/22, 3/18/22, 3/25/22 and 3/30/22. There were no clinical notes in Patient 10's record of these visits. During an interview on 4/4/22, at 2:52 p.m., the DPCS the expectation is to document on the patient record. The DPCS stated "if it was not documented, it was not done". A review of the HA's undated document titled, "Submission of Documentation", indicated " ...4.Clinical Notes time schedule, every Monday no later than 5:00 p.m."

Based on interview and record review, the hospice agency (HA) failed to ensure the clinical records contained the admission orders, plan of care (POC), medication orders that were signed and/or dated by the physician, the interdisciplinary group (IDG) prepared the patient's POC in developing the patient's care plan, and evidence the hospice attending physician communicated with the primary physician, to certify the patients had a life expectancy of six months or less, if the terminal illness runs it normal course for seven of 11 sampled patients (Patient 1,2, 3,8,9,10, and 11, ) These deficient practices resulted in the physician orders that were not signed to provide care or verifying the patients' orders and plan of care, and potential for iniability to evaluate care provided to the patients. Findings: a. A review of Patient 1's electronic clinical record indicated a start of hospice care date of 11/8/21, with a terminal diagnosis of atherosclerosis (a build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) of coronary artery bypass graft (CABG, a surgical procedure used to treat coronary heart disease. It diverts blood diverting blood around narrowed or clogged parts of the major arteries to improve blood flow and oxygen supply's to heart), without angina pectoris (chest pain or discomfort due to coronary artery disease). A review of Patient 1's "Physician's Certification for Hospice Benefit" for the first 90- day period from 11/8/2021 to 2/5/2022, indicated Patient 1's terminal diagnosis was atherosclerosis of coronary artery bypass Graft(S) without angina pectoris. There was no documented evidence of interdisciplinary group (IDG) meeting minutes. A review of Patient 1's admission orders, POC, Medication orders were not signed or dated by the physician. b. On 4/2/22, a review of Patient 2's electronic clinical record, indicated a start of hospice care date 11/6/21, with terminal diagnosis of heart failure,uUnspecified ( a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of Patient 2's "Physician's Certification Hospice Benefit '' for the first 90 day period, from 11/6/21 to 2/3/22, indicated Patient 2's terminal diagnosis was heart failure, unspecified. There was no documented evidence the hospice attending physician communicated with the primary physician, to certify that Patient 2 had a life expectancy of six months or less, if the terminal illness runs it normal course. A review of Patient POC/Interdisciplinary group dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, indicated there were no IDG notes in Patient 2's electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 2's care plan. c. On 4/9/22, a review of Patient 3's electronic clinical record indicated a start of hospice care date of 11/6/21, with a terminal diagnosis of atherosclerotic heart disorder of native coronary artery without angina pectoris without chest pain or discomfort due to coronary artery disease). A review of Patient 3's "Physician's Certification for Hospice Benefit" for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 3's terminal diagnosis was atherosclerotic heart disorder of native coronary artery without angina pectoris. A review of Patients POC/Interdisciplinary group dated 11/16/21, 11/30/21, 12/4/21, 12/28/21, 1/11/22, 1/25/22, there were no more IDG notes in Patient 3's electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 3's care plan. d. A review of Patient 11's electronic clinical record, indicated a start of hospice care date 1/11/22, with terminal diagnosis of Heart Failure Unspecified(a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of Patient 11's "Physician's Certification for Hospice Benefit" for the first 90- day period from 11/6/2021 to 2/3/2022, indicated Patient 1's terminal diagnosis was Atherosclerotic Heart Disorder of Native Coronary artery without again pectoris. A review of Patients POC/Interdisciplinary group dated 1/11/22, 1/25/22, there were no more IDG notes in patient 1's e;electronic clinical record and the IDG notes in the clinical record indicated there were no physician's signatures for attendance. There was no documented evidence the IDG prepared the POC in consultation with the physician, MSW, chaplain participated in developing Patient 3's care plan. During a telephone interview with the social worker on 4/4/22, she stated she does not attend the IDG meeting. During an interview with the DPCS on 2/5/22, at 2: 20 pm, stated the hospice and all disciplines in the IDG has not had IDG meeting since she started at the agency on 1/16/2022 and that no discipline is involved in the IDG including the Medical Doctor. A review of the agency's policy and procedure on Interdisciplinary Group Meetings revised 11/2017, stipulates," the Interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes in progress and update to the plan of care, deaths and changes in the patient and family/caregiver circumstances, referrals, andadmission/certification and recertification of patients on the hospice program. Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. The meeting will be facilitated by the hospice Clinical Supervisor/Nursing Supervisor or designee. The hospice Medical Director and all hospice interdisciplinary group members will be present,including volunteers and attending physicians, as available. The patient and family/caregiver would be informed of the schedule for this meeting, its purpose and that the discussion is confidential. e. A review of Patient 8's admission record indicated the patient was admitted to the HA on 1/8/22, with a primary diagnosis of Alzheimer's disease. A review of Patient 8's medical record titled, "Physician Order Details," dated 1/8/22, indicated "Orders type: Admission Order." The physician order did not indicate the MD had signed the orders. f.A review of Patient 9's admission record indicated the patient was admitted to the HA on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 9's medical record titled, "Physician Order Details," dated 2/13/22, indicated "Orders type: Admission Order." The physician order did not indicate the MD had signed the orders. g. A review of Patient 10's admission record indicated the patient was admitted to the HA on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. A review of Patient 10's medical record titled, "Physician Order Details" dated 3/2/22, indicated "Orders type: Admission Order." The physician order did not indicate the MD had signed the orders. During an interview on 4/5/22, at 10:30 a.m., the DPCS stated the MD is supposed to sign the admission orders within 48 hours. During an interview on 4/5/22, at 11:02 a.m., MD stated, "Like I said, I am a little behind with my documentation. I have been really behind in signing all the charts. I have been very busy . I have not had time to review and chart." A review of the HA's policy and procedures titled, "Job Descriptions Hospice Medical Director", dated April 2020, indicated " ...4.Adhering to requirements, terms, and conditions required by Medicare Conditions of Participation, accrediting body, and federal and state statutes governing the provision of services."

Based on interview and record review, the hospice agency (HA) failed to ensure the clinical records were authenticated for three of 11 sampled patients (Patients 8, 9, and 10). This deficient practice resulted in patient care records not being validated for the care received. Findings: a. A review of Patient 8's admission record indicated the patient was admitted to the HA on 1/8/22, with a primary diagnosis of Alzheimer's disease. A review of Patient 8's clinical record titled, "Creed Hospice Inc", dated 1/8/22, indicated "Z0500. Signature of Person Verifying Record Completion," typed name. b. A review of Patient 9's admission record indicated the patient was admitted to the HA on 2/13/22, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (a chronic lung condition causing difficulty in breathing). A review of Patient 9's undated clinical record titled, "Nursing Clinical Note", indicated a visit was made. The record did not specify the date the visit occurred, nor did it have the signature of the nurse providing care. c. A review of Patient 10's admission record indicated the patient was admitted to the HA on 3/2/22 with a primary diagnosis of Chronic Obstructive Pulmonary Disease. A review of Patient 10's medical record titled, "Hospice Aide Progress Note," dated 3/13/22, did not indicate a signature of the hospice aide providing care. During an interview on 4/5/22, at 10:30 a.m., the DPCS stated medical records should have a signature on the document indicating it should be approved. During an interview on 4/5/22, at 11:45 a.m., the DPCS stated the electronic signature "should say e-sign, that means they have signed the document. The name on the document is typed, it is not their signature." A review of the HA's undated policy and procedure titled, "Electronic Signature, Attestation, and Authorship", indicated "An e-signature event captures and displays the e-signature, author's name, credentials, date, and time of application ...Accompanying signature phrases approved and acceptable for EHR authentication statements are identified. Phrases selected should be fitting to the type of documentation referenced. Examples include "electronically signed by" ..."

Based on interview and record review, the hospice agency (HA) failed ensure that two of 11 sampled patients ( Patient 2 and 3) that were discharged from the hospice agency had a discharge summary that included a summary of the patients stay, treatments, symptoms, current plan of care, pain management, patients last physician orders and any other documents. This deficient practice had the potential for not ensuring continuity of care was provided after the patients were discharged. Findings: A review of Patient 2's electronic clinical record, indicated a start of hospice care date 11/6/21, with terminal diagnoses of heart failure, unspecified ( a disorder characterized by the inability of the heart to pump blood at an adequate volume to meet what your body needs to stay alive). A review of Patient 2's '"Physician's Certification Hospice Benefit '' for the first 90 day period, from 11/6/21 to 2/3/22, indicated Patient 2's terminal diagnosis was heartf failure, unspecified. There was no documented evidence the hospice attending physician communicated with the primary physician, to certify that Patient 2 had a life expectancy of six (6) months or less, if the terminal illness runs it normal course. A review Patient 2's Initial Nursing Assessment visit by RN dated 11/6/21, indicated Patient 2 was oriented, depressed, anxiety, has functional limitation of endurance and ambulation, fatigues easily and with imminence of death within 72 hours. A review of Patient 2's "Initial orders and Plan of Care" dated 11/6/2021, indicated the skilled nurse (SN) visit frequency for Patient 2 was once a week and two visits as needed for symptom management, nursing assessment of patient/caregiver needs, evaluation of patient/caregiver response to effectiveness of intervention, development of patient/cg care plan/intervention in collaboration with interdisciplinary team (IDT). It instructed the social worker to visit once a month to assess, evaluation. A review of Patient 2's " Summary/Plan/Support Diagnosis, Indicated" Patient 2 was admitted to hospice under routine level of care for comfort, pain management and symptom management for the 1st period of 11/6/21 to 2/3/22,. Due to patients' poor prognosis and worsening comorbidities and rapid decline in condition the patient and family wishes no further aggressive treatment and have now opted those services of hospice comfort care, pain management and symptom management only. It also indicated Patient 2 is eating 50-60% less, appeared generally weak and tired, requires maximum assistance with activities of daily living care and that Patient 3 is able to ambulate with short distances, 5-10 steps with assistive device." There was no signature of the physician and there was no discharge summary completed by the IDG. b. a review of Patient 3's electronic clinical record indicated a start of hospice care date of 11/6/21, with a terminal diagnosis of atherosclerotic heart disorderoOf native coronary artery without angina pectoris ( The build-up of fats, cholesterol plaque in the walls of the arteries causing obstruction of blood flow) without chest pain or discomfort due to coronary artery disease). A review of Patient 3's "Physician's Certification for Hospice Benefit" for the first 90 day period from 11/6/2021 to 2/3/2022, indicated Patient 3's terminal diagnosis was atherosclerotic heart disorder of native coronary artery without angina pectoris. There was no documented discharge summary in Patient 3's clinical record. A review of the hospice agency's policy and procedure Discharge From Hospice Program revised 11/2017, stipulates, "The medical director and/or attending physician determine the patient is not hospice-appropriate, according to the standard clinical criteria for determining disease prognosis of six (6) months or less. The hospice interdisciplinary group will develop a discharge plan which includes the possibility that a patient's condition might stabilize or change such that the patient cannot be certified as terminally ill. The discharge planning, process will include any necessary family counseling, patient education or other services needed prior to discharge."

Based on observation, interview and record review, the hospice agency failed to ensure patients were provided with comfort kits for two of 13 sampled patients (Patient 3 and 5). This deficient practice can prevent the patient from receiving benefit of comforting medication during the end of life experience. Findings: b. A review of Patient 5's clinical record indicated, the patient started hospice care on 12/28/21, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD). It was indicated the Medical Director was the referring/attending/patient choice doctor. A review of the Plan of Care (POC)/Interdisciplinary group (IDG) Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The Skilled Nurse (SN) visit was once a week and as needed. The Medical Social Worker (MSW) visit was on initial assessment, certification and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. During a joint home visit with RN 1 on 9/7/2022, at 10:20 a.m., Patient 5 was observed walking with a cane from her car. Patient was alert, oriented, and was able to communicate well. At 10:55 a.m., when asked about the comfort kit, both RN 1 and Patient 5 did not know where the comfort kit was. A review of Patient 5's record indicated there was no documented evidence the comfort kit was provided to Patient 5. The agency was not able to provide the documented evidence the comfort kit was provided to Patient 5 except the receipt dated 9/9/2022, two days after the surveyor mentioned about the missing comfort kit. The policy regarding the Comfort kit was not provided by the agency.