Every finding on record at Dependable Hospice & Palliative Care Inc

Based on observation, interview and record review, the hospice agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid programs [a joint federal and state program that helps cover medical costs for some people with limited income and resources] regarding Initial and Comprehensive Assessment of Patients was met as follows: 1. HA failed to conduct a comprehensive assessment that reflects the patient's current health status and identified needs for hospice care to be certified to receive continued hospice benefits in the management of terminal illness (a disease or condition due to which a patient's death is anticipated in six months) for one out of six sampled patients (Patient 23). This deficient practice resulted in the patient being recertified for hospice care lacking the documented evidence of an accurate comprehensive assessment conducted by the healthcare professionals for the patient to receive continued hospice benefits. Refer to L524. 2. HA failed to coordinate with the patient's primary care physician in order to obtain the medical history and assessment of the current health status for one of six sampled patients (Patient 23). The deficient practice resulted in the patient being certified for hospice with no gathered clinical information and completed accurate assessment of the patient's health status from the primary physician. Refer to L525. The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (written rules or law) mandated compliance with Federal (government) regulation for Initial and Comprehensive Assessment of Patient to ensure the provision of quality healthcare are being provided to patients certified to receive the hospice benefits.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to conduct a comprehensive assessment that reflects the patient's current health status, and identified needs for hospice care to be certified to receive continued hospice benefits in the management of terminal illness (a disease or condition due to which a patient's death is anticipated in six months) for one out of six sampled patients (Patient 23). This deficient practice resulted in the patient being recertified for hospice care lacking the documented evidence of a comprehensive assessment conducted by the healthcare professionals for the patient to receive continued hospice benefits. --- A review of Patient 23s Patient Face Sheet (admission information record) indicated a start of care (SOC) date of 10/18/2024, with a terminal diagnosis chronic obstructive pulmonary disease (COPD- A group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 23's Physicians Certification for Hospice Benefit, dated 10/18/2024 to 1/15/2025, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 23 had a life expectancy of six months or less if the terminal illness runs its normal course. The document indicated that Patient 23 was admitted with a terminal diagnosis of COPD. A review of Patient 23's Physicians Certification for Hospice Benefit, dated 1/16/2025 to 4/15/2025, benefit period #2, indicated the Physician 2 signed the attending physician referral section to indicate Patient 23 had a life expectancy of six months or less if the terminal illness runs its normal course. The document indicated that Patient 23 was admitted with a terminal diagnosis of COPD. A review of Patient 23s Referral Form, dated 10/16/2024, indicated the referring physician as Physician 4. A review of Patient 23s LCD Hospice Eligibility Determination (a tool used by the agency to help determine eligibility for hospice services), dated 1/13/2025, indicated that Patient 23 was not poorly or not responsive to bronchodilators which resulted in a loss of functional abilities resulting (the ability to perform daily tasks such as walking, dressing, showering). The document also indicated that Patient 23 had recent increasing emergency room visits, respiratory failure (a life threatening condition when not enough oxygen passes from your lungs to your blood), increased home visits by physician, and hypoxemia at rest on room air, as evidenced by pO2 < less than or equal to 55 mmHg (low levels of oxygen in your blood causing symptoms like headache, difficulty breathing, rapid heart rate and bluish skin, mmHg, millimeters of Mercury, unit of measurement used to calculate the oxygen pressure in blood). A review of Patient 23s Updated Assessment (an updated comprehensive assessment which was conducted by a registered nurse during recertification of hospice to include and support the current health status of the patient), dated 1/13/2025, indicated oxygen saturation (a measurement of the amount of oxygen found in blood) of 98 % (A normal level of oxygen is usually 95% or higher. Some people with chronic lung disease can have normal levels around 90%), on room air. During a joint home visit on 2/26/2025, at 12:30 p.m., with Licensed Vocational Nurse (LVN 1) at Patient 23s residence, Patient 23 was observed walking approximately 50 feet to unlock a security gate to let visiting team enter her living complex and then observed walking approximately 50 feet back to her apartment. She was observed walking independently, without a walker. She walked without stopping to rest. She was able to speak during the ambulating, without any visible or audible signs of breathing difficulty. During an interview and observation on 2/26/2025 at 12:35 pm, Patient 23 stated that she learned about the hospice agency through a friend that had home care services. Patient 23 stated that her friend received home care and that she thought she could benefit from it too. When asked who her primary care physician was, she stated Physician 3. Patient 23 did not know who Physician 4 was. Patient 23 stated that she did not learn about the hospice agency from her primary care physician (Physician 3), who has been her physician for a long time. Patient 23 stated that she did not have any emergency room visits in about a year or had increased visits to a physician. She stated that she had seen Physician 3 once in 2024. Patient 23 stated that her main health concern was stomach issues due to a gall bladder (a small, pear-shaped organ in the upper-right abdomen) surgery over a year ago. During an observation and interview on 2/26/2025 at 12:35 pm, LVN 1 was observed taking vital signs for Patient 23. Patient 23s was seated on the couch, breathing without any additional oxygen administration, breathing room air. Patient 23's heart rate was 68 (normal resting heart rate for adult ranges from 60 to 100 beats per minute), oxygen saturation (a measurement of the amount of oxygen found in blood) 94% (A normal level of oxygen is usually 95% or higher. Some people with chronic lung disease can have normal levels around 90%), Respiratory Rate (breathes taken per minute), 22 (normal respiratory rate for healthy adults is between 12–20 breaths per minute). The oxygen concentrator is observed to have unused tubing in a bag attached to it. During an interview on 2/25/2025 at 12:59 pm, LVN 1 stated that Patient 23 does not need a walker or assistive device to walk. During an interview on 2/25/2025 at 1:35 pm, office staff (staff 1) for Physician 3, stated that Patient 23 had visited Physician 3 on 10/17/2024 (one day before hospice admission). Staff 1 stated there was no record of Patient 23 needing hospice services or having a terminal diagnosis. During a record review of Patient 23s Physician Progress Notes, dated 10/17/2025, Physician 3 indicated that Patient 23s primary concern were lower back pain and knee issues. Physician 3 recorded respiratory rate of 16 with normal lung sounds. The document further indicated that the Patient 23s ability level to wash, shower, bathe and walk was ";easy" for her to perform. During a phone interview on 2/27/2025 at 9:45 am with Patient 23s primary care physician (Physician 3), Physician 3 stated, ";I have been the seeing Patient 23 for a few years now. Last time she was in my office was October 17, 2024. During that appointment we discussed referrals for orthopedics for a possible knee surgery and she was saying she has back pain too. As far as medical history, Patient 23 has chronic bilateral knee pain, but she doesnt use any assistive device for ambulation. She also has arthritic back pain. Other than that, she has hypertension and very well controlled COPD. I was unaware she was on hospice. Who signed her up for hospice? She was not a hospice patient. She doesnt have any terminal conditions. She has pain and has drug seeking behavior. As you can see in my notes, I put no Soma or opiates. She had several incidents where she came in saying her purse got snatched and the opiates were inside, and she needed refills. Its never the laxatives or the blood pressure medications that go missing, its always the opiates. But this is definitely fraud, this patient is not a qualified hospice patient. No one has contacted me about her qualification, had they I would have told them just that. She has never had respiratory failure, and there is no record in here that she has had hospitalizations or ER visits. No record of home physician or telehealth visits. There was no documentation of a PO2 of less that 55 %. As far as needed assistance with ADLs, I have here that she can do ADLs with ease." During a concurrent interview and record review on 2/27/2025 at 11:52 am., with Director of Patient Care Services Designee (DPCSD) stated, Patient 23s clinical record ";LCD guidelines indicated increased trips to ER- no, I dont think so. I dont think their condition warrants to go to ER. Respiratory failure, we dont have this diagnosis, our diagnosis is COPD, not correct for respiratory failure, no proof of this. Increasing physician home visits, no documented proof of this. Hypoxemia PO2 55 mmHg means no oxygen, we dont have proof of this." During a concurrent interview and record review on 2/27/2025 at 12:07 pm., with Director of Patient Care Services Designee (DPCSD) of Patient 23s clinical record DPCSD stated," When enrolling in hospice we check for eligibility with insurance. Look for a referral and of course we talk to the primary care physician of the patient. I double checked hard file for Patient 23 and all uploaded clinical notes, there is no record in the patient's files indicated frequent ER visits, increased physician home visits, any evidence of respiratory failure, or PO2 of less than or equal to 55 mmHg." A review of the HAs policy and procedure titled, ";Comprehensive Assessment" revised April, 2020, the policy and procedure indicated, ";1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient's clinical record, including at least the following information, as relevant: C. Nature and condition causing admission (including the presence or lack of objective data and subjective complaints) G. 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 K. Patient's past and present medical and psychosocial history including pertinent diagnosis and any co-morbid conditions. L. Name and address of the patient's attending physician M, Name of the hospital and other agencies or persons involved in the past and present care of the patient. Q. Review of current and related past medications, including prescription and over-the-­counter medications, allergy history and other medication information, including but not limited to identification of the following: 1. Effectiveness drug therapy 2. Unwanted side and toxic effects 3. Drug interactions (actual or potential) 4. Duplicate drug therapy 5. Drug therapy currently associated with laboratory monitoring 6. Whether the medication is unrelated to the terminal illness or related conditions (ensure that there is clinical documentation to support unrelatedness), X. Laboratory results, Y. Medical, alcohol, and other drug history." The policy further indicated, ";2. The assessment should determine: A Probable prognosis of six (6) months or less B. Patient problems and needs related to the terminal illness C. Patient goals related to the terminal illness." A review of the agency's policy and procedure titled "Admission Criteria and Process", revised November 2020, the policy and procedure indicated, ";Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician." The policy and procedure further indicated, ";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, utilizing standard clinical prognosis criteria developed by LCD."

Based on observation, interview and record review the hospice agency failed to coordinate with the patient's primary care physician in order to obtain the medical history and assessment of the current health status for one of six sampled patients (Patient 23). The deficient practice resulted in the patient being certified for hospice with no gathered clinical information and assessment of the patient's health status from the primary physician. --- A review of Patient 23s Patient Face Sheet (admission information record) indicated a start of care (SOC) date of 10/18/2024, with a terminal diagnosis chronic obstructive pulmonary disease (COPD- A group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 23's Physicians Certification for Hospice Benefit, dated 10/18/2024 to 1/15/2025, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 23 had a life expectancy of six months or less if the terminal illness runs its normal course. The document indicated that Patient 23 was admitted with a terminal diagnosis of COPD. A review of Patient 23's Physicians Certification for Hospice Benefit, dated 1/16/2025 to 4/15/2025, benefit period #2, indicated the Physician 2 signed the attending physician referral section to indicate Patient 23 had a life expectancy of six months or less if the terminal illness runs its normal course. The document indicated that Patient 23 was admitted with a terminal diagnosis of COPD. A review of Patient 23s Referral Form, dated 10/16/2024, indicated the referring physician as Physician 4. A review of Patient 23s LCD Hospice Eligibility Determination (a tool used by the agency to help determine eligibility for hospice services), dated 1/13/2025, indicated that Patient 23 was not poorly or not responsive to bronchodilators which resulted in a loss of functional abilities resulting (the ability to perform daily tasks such as walking, dressing, showering). The document also indicated that Patient 23 had recent increasing emergency room visits, respiratory failure (a life threatening condition when not enough oxygen passes from your lungs to your blood), increased home visits by physician, and hypoxemia at rest on room air, as evidenced by pO2 < less than or equal to 55 mmHg (low levels of oxygen in your blood causing symptoms like headache, difficulty breathing, rapid heart rate and bluish skin, mmHg, millimeters of Mercury, unit of measurement used to calculate the oxygen pressure in blood). A review of Patient 23s Updated Assessment (an updated comprehensive assessment which is conducted by a registered nurse during recertification of hospice to include and support the current health status of the patient), dated 1/13/2025, indicated oxygen saturation (a measurement of the amount of oxygen found in blood) of 98 % (A normal level of oxygen is usually 95% or higher. Some people with chronic lung disease can have normal levels around 90%), on room air. During a joint home visit on 2/26/2025, at 12:30 p.m., with Licensed Vocational Nurse (LVN 1) at Patient 23s residence, Patient 23 was observed walking approximately 50 feet to unlock a security gate to let visiting team enter her living complex and then observed walking approximately 50 feet back to her apartment. She was observed walking independently, without a walker. She walked without stopping to rest. She was able to speak during the ambulating, without any visible or audible signs of breathing difficulty. During an interview and observation on 2/26/2025 at 12:35 pm, Patient 23 stated that she learned about the hospice agency through a friend that had home care services. She stated that her friend received home care and that she thought she could benefit from it too. When asked who her primary care physician is, she stated Physician 3. States she does not know who Physician 4 is. She stated that she did not learn about the agency through her primary care physician (Physician 3), who has been her physician for a long time. Patient 23 stated that she has not had any emergency room visits in approximately a year or increased visits to a physician. She states that she remembers seeing her Physician 3 once in 2024. Patient 23 stated that her main health concern was stomach issues due to a gall bladder (a small, pear-shaped organ in the upper-right abdomen) surgery over a year ago. During an observation and interview on 2/26/2025 at 12:35 pm, LVN 1 was observed taking vital signs for Patient 23. Patient 23s was seated on the couch, breathing without any additional oxygen administration, breathing room air. Her heart rate was 68 (normal resting heart rate for adults ranges from 60 to 100 beats per minute), oxygen saturation (a measurement of the amount of oxygen found in blood) 94% (A normal level of oxygen is usually 95% or higher. Some people with chronic lung disease can have normal levels around 90%), Respiratory Rate (breathes taken per minute), 22 (normal respiratory rate for healthy adults is between 12–20 breaths per minute). The oxygen concentrator is observed to have unused tubing in a bag attached to it. During an interview on 2/25/2025 at 12:59 pm, LVN 1 stated that Patient 23 does not need a walker or assistive device to walk. During an interview on 2/25/2025 at 1:35 pm, office staff (staff 1) for Physician 3, stated that Patient 23 had visited Physician 3 on 10/17/2024 (one day before hospice admission). Staff 1 stated there was no record of Patient 23 needing hospice services or having a terminal diagnosis. During a record review of Patient 23s Physician Progress Notes, dated 10/17/2025, Physician 3 indicated that Patient 23s primary concern were lower back pain and knee issues. Physician 3 recorded respiratory rate of 16 with normal lung sounds. The document further indicated that the Patient 23s ability level to wash, shower, bathe and walk was ";easy" for her to perform. During a phone interview on 2/27/2025 at 9:45 am with Patient 23s primary care physician (Physician 3), Physician 3 stated, ";I have been the seeing Patient 23 for a few years now. Last time she was in my office was October 17th, 2024. I see at that appointment we discussed referrals for orthopedics for a possible knee surgery and she was saying she has back pain too. As far as medical history, Patient 23 has chronic bilateral knee pain, but she doesnt use any assistive device for ambulation. She also has arthritic back pain. Other than that, she has hypertension and very well controlled COPD. I was unaware she is on hospice. Who signed her up for hospice?! She is not a hospice patient. She doesnt have any terminal conditions. She has pain and has drug seeking behavior. As you can see in my notes, I put no Soma or opiates. She had several incidents where she came in saying her purse got snatched and the opiates were inside, and she needed refills. Its never the laxatives or the blood pressure medications that go missing, its always the opiates. But this is definitely fraud, this patient is not a qualified hospice patient. No one has contacted me about her qualification, had they I would have told them just that. She has never had respiratory failure, and there is no record in here that she has had hospitalizations or ER visits. No record of home physician or telehealth visits. There is no documentation of a PO2 of less that 55 %. As far as needed assistance with ADLs, I have here that she can do ADLs with ease." During a phone interview on 2/27/2025 at 11:21 am., with the current Medical Director of the hospice agency (Physician 5) Physician 5 stated, ";I have been with this agency for about 6 weeks, its basically a new team that we have. I am the medical director; I have been doing hospice for about 7 years." When asked how a patient is certified for hospice, MD stated, ";for me, first screen the patient, they come from referral, our job is to screen and make sure they are eligible, get the history and physical, then nurse does assessment, if we think they are 6 month or meet lcd criteria, for recertification, I do an actual visit, I go there. We havent come across that yet since Ive been here. I would communicate with the attending physician of the patient and make sure they are qualified. I would go over all documents that support the LCD criteria. KPS 40 usually when they are non-ambulatory. There is a list. We are usually looking for 50% or lower, unless terminal cancer. We use it for everyone as a rough guideline. We use it for criteria, it gives us an idea on their functional capacity, 40% is general non ambulatory, confusion also, level of disability, including ADLs, I have not seen Patient 23. I have not communicated with her attending physician. The office does that and if there are any updates they let me know. They are the central hub. I did not certify this patient. The previous doctor did. We do IDGs on Mondays. We did discuss this patient during IDGs, but I dont remember off the top of my head about this patient. I am not at a computer." Discussed observations of patient during home visit, Physician 5 stated, ";No that does not sound like a KPS 40 usually they are bed bound. Sounds like 60-70. Unfortunately, we just started with a new team. We are not aware of that. I communicate with the Administrator, not sure who the DPCS is. I have never met them. Unless they were in the IDG. We have a large group. No, I dont think this Patient qualifies for hospice. I can see what happened with the previous team, we took over and this Patient is not a good eligible patient for hospice. Thats the situation its what it sounds like. This patient should not have been on hospice. Our team did not catch that." During a concurrent interview and record review on 2/27/2025 at 11:52 am with Director of Patient Care Services Designee (DPCSD), Patient 23s clinical record DPCSD stated, ";LCD guidelines indicate increased trips to ER- no, I dont think so. I dont think their condition warrants to go to ER. Respiratory failure, we dont have this diagnosis, our diagnosis is COPD, not correct for respiratory failure, no proof of this. Increasing physician home visits, no documented proof of this. Hypoxemia po2 55 mmHg means no oxygen, we dont have proof of this." During a concurrent interview and record review on 2/27/2025 at 12:07 pm., with Director of Patient Care Services Designee (DPCSD), Patient 23s clinical record DPCSD stated," When enrolling in hospice we check for eligibility with insurance. Look for a referral and of course we talk to the primary care physician of the patient. I double checked hard file for Patient 23 and all uploaded clinical notes, there is no record in the patient's files indicated frequent ER visits, increased physician home visits, any evidence of respiratory failure, or PO2 of less than or equal to 55 mmHg." A review of the HAs policy and procedure titled, ";Comprehensive Assessment" revised April, 2020, the policy and procedure indicated, ";1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient's clinical record, including at least the following information, as relevant: C. Nature and condition causing admission (including the presence or lack of objective data and subjective complaints) G. 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 K. Patient's past and present medical and psychosocial history including pertinent diagnosis and any co-morbid conditions. L. Name and address of the patient's attending physician M, Name of the hospital and other agencies or persons involved in the past and present care of the patient. Q. Review of current and related past medications, including prescription and over-the-­counter medications, allergy history and other medication information, including but not limited to identification of the following: 1. Effectiveness drug therapy 2. Unwanted side and toxic effects 3. Drug interactions (actual or potential) 4. Duplicate drug therapy 5. Drug therapy currently associated with laboratory monitoring 6. Whether the medication is unrelated to the terminal illness or related conditions (ensure that there is clinical documentation to support unrelatedness), X. Laboratory results, Y. Medical, alcohol, and other drug history." The policy further indicated, ";2. The assessment should determine: A Probable prognosis of six (6) months or less B. Patient problems and needs related to the terminal illness C. Patient goals related to the terminal illness." A review of the hospice agency's policy and procedure titled "Admission Criteria and Process", revised November 2020, the policy and procedure indicated, ";Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician." The policy and procedure further indicated, ";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, utilizing standard clinical prognosis criteria developed by LCD."

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation for Medical Director was met as evidenced by: 1. The hospice agency (HA) failed to ensure the Medical Director and/or physician designee conducted an assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Recertification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for one of six sampled patients (Patient 23). (Refer to L668). 2. The HA 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 patients clinical information necessary for initial certification and recertification of terminal illness for one of six sampled patients (Patient 23). (Refer to L669). The cumulative effect of this systemic practice resulted in the failure of the hospice agency to deliver statutorily mandated compliance with Federal regulation for Medical Director to ensure the highest quality of patient care was provided to the patients certified to receive hospice services.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Medical Director and/or physician designee conducted an assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (a hospice physician narrative designed to explain the clinical findings that support a life expectancy of six months or less), to qualify for hospice care and services (health care that focuses on the palliation to ease the symptoms without curing the underlying disease of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) for one of six sampled patients (Patient 23). This deficient practice resulted in the Medical Director certifying this patient without clinical documentation to receive the hospice benefits. --- A review of Patient 23s Patient Face Sheet (admission information record) indicated a start of care (SOC) date of 10/18/2024, with a terminal 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 23's Physicians Certification for Hospice Benefit, dated 10/18/2024 to 1/15/2025, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 23 had a life expectancy of six months or less if the terminal illness runs its normal course. The document indicated that Patient 23 was admitted with a terminal diagnosis of COPD. A review of Patient 23's Physicians Certification for Hospice Benefit, dated 1/16/2025 to 4/15/2025, benefit period #2, indicated the Physician 2 signed the attending physician referral section to indicate Patient 23 had a life expectancy of six months or less if the terminal illness runs its normal course. The document indicated that Patient 23 was admitted with a terminal diagnosis of COPD. A review of Patient 23s Referral Form, dated 10/16/2024, indicated the referring physician as Physician 4. A review of Patient 23s LCD Hospice Eligibility Determination (a tool used by the agency to help determine eligibility for hospice services), dated 1/13/2025, indicated that Patient 23 was not poorly or not responsive to bronchodilators which resulted in a loss of functional abilities resulting (the ability to perform daily tasks such as walking, dressing, showering). The document also indicated that Patient 23 had recent increasing emergency room visits, respiratory failure (a life threatening condition when not enough oxygen passes from your lungs to your blood), increased home visits by physician, and hypoxemia at rest on room air, as evidenced by pO2 < less than or equal to 55 mmHg (low levels of oxygen in your blood causing symptoms like headache, difficulty breathing, rapid heart rate and bluish skin, mmHg, millimeters of Mercury, unit of measurement used to calculate the oxygen pressure in blood). A review of Patient 23s Updated Assessment (an updated comprehensive assessment which is conducted by a registered nurse during recertification of hospice to include and support the current health status of the patient), dated 1/13/2025, indicated oxygen saturation (a measurement of the amount of oxygen found in blood) of 98 % (A normal level of oxygen is usually 95% or higher. Some people with chronic lung disease can have normal levels around 90%), on room air. During a joint home visit on 2/26/2025, at 12:30 p.m., with Licensed Vocational Nurse (LVN 1) at Patient 23s residence, Patient 23 was observed walking approximately 50 feet to unlock a security gate to let visiting team enter her living complex and then observed walking approximately 50 feet back to her apartment. She was observed walking independently, without a walker. She walked without stopping to rest. She was able to speak during the ambulating, without any visible or audible signs of breathing difficulty. During an interview and observation on 2/26/2025 at 12:35 pm., Patient 23 stated that she learned about the hospice agency through a friend that had home care services. She stated that her friend received home care and that she thought she could benefit from it too. When asked who her primary care physician was, Patient 23 stated Physician 3. Patient 23 did not know who Physician 4 was. Patient 23 stated that she did not learn about the hospice agency from her primary care physician (Physician 3), who has been her physician for a long time. Patient 23 stated that she has not had any emergency room visits in approximately a year or increased visits to a physician. She states that she remembers seeing her Physician 3 once in 2024. Patient 23 stated that her main health concern was stomach issues due to a gall bladder (a small, pear-shaped organ in the upper-right abdomen) surgery over a year ago. During an observation and interview on 2/26/2025 at 12:35 pm, LVN 1 was observed taking vital signs for Patient 23. Patient 23s was seated on the couch, breathing without any additional oxygen administration, breathing room air. Her heart rate was 68 (normal resting heart rate for adults ranges from 60 to 100 beats per minute), oxygen saturation (a measurement of the amount of oxygen found in blood) 94% (A normal level of oxygen is usually 95% or higher. Some people with chronic lung disease can have normal levels around 90%), Respiratory Rate (breathes taken per minute), 22 (normal respiratory rate for healthy adults is between 12–20 breaths per minute). The oxygen concentrator is observed to have unused tubing in a bag attached to it. During an interview on 2/25/2025 at 12:59 pm, LVN 1 stated that Patient 23 does not need a walker or assistive device to walk. During an interview on 2/25/2025 at 1:35 pm, office staff (staff 1) for Physician 3, stated that Patient 23 had visited Physician 3 on 10/17/2024 (one day before hospice admission). Staff 1 stated there was no record of Patient 23 needing hospice services or having a terminal diagnosis. During a record review of Patient 23s Physician Progress Notes, dated 10/17/2025, Physician 3 indicated that Patient 23s primary concern were lower back pain and knee issues. Physician 3 recorded respiratory rate of 16 with normal lung sounds. The document further indicated that the Patient 23s ability level to wash, shower, bathe and walk was ";easy" for her to perform. During a phone interview on 2/27/2025 at 9:45 am with Patient 23s primary care physician (Physician 3), Physician 3 stated, ";I have been the seeing Patient 23 for a few years now. Last time she was in my office was October 17th, 2024. I see at that appointment we discussed referrals for orthopedics for a possible knee surgery and she was saying she has back pain too. As far as medical history, Patient 23 has chronic bilateral knee pain, but she doesnt use any assistive device for ambulation. She also has arthritic back pain. Other than that, she has hypertension and very well controlled COPD. I was unaware she is on hospice. Who signed her up for hospice?! She is not a hospice patient. She doesnt have any terminal conditions. She has pain and has drug seeking behavior. As you can see in my notes, I put no Soma or opiates. She had several incidents where she came in saying her purse got snatched and the opiates were inside, and she needed refills. Its never the laxatives or the blood pressure medications that go missing, its always the opiates. But this is definitely fraud, this patient is not a qualified hospice patient. No one has contacted me about her qualification, had they I would have told them just that. She has never had respiratory failure, and there is no record in here that she has had hospitalizations or ER visits. No record of home physician or telehealth visits. There is no documentation of a PO2 of less that 55 %. As far as needed assistance with ADLs, I have here that she can do ADLs with ease." During a phone interview on 2/27/2025 at 11:21 am with the current Medical Director of the hospice agency (Physician 5) Physician 5 stated, ";I have been with this agency for about 6 weeks, its basically a new team that we have. I am the medical director; I have been doing hospice for about 7 years." When asked how a patient is certified for hospice, MD stated, ";for me, first screen the patient, they come from referral, our job is to screen and make sure they are eligible, get the history and physical, then nurse does assessment, if we think they are 6 month or meet lcd criteria, for recertification, I do an actual visit, I go there. We havent come across that yet since Ive been here. I would communicate with the attending physician of the patient and make sure they are qualified. I would go over all documents that support the LCD criteria. KPS 40 usually when they are non-ambulatory. There is a list. We are usually looking for 50% or lower, unless terminal cancer. We use it for everyone as a rough guideline. We use it for criteria, it gives us an idea on their functional capacity, 40% is general non ambulatory, confusion also, level of disability, including ADLs, I have not seen Patient 23. I have not communicated with her attending physician. The office does that and if there are any updates they let me know. They are the central hub. I did not certify this patient. The previous doctor did. We do IDGs on Mondays. We did discuss this patient during IDGs, but I dont remember off the top of my head about this patient. I am not at a computer." Discussed observations of patient during home visit, Physician 5 stated, ";No that does not sound like a KPS 40 usually they are bed bound. Sounds like 60-70. Unfortunately, we just started with a new team. We are not aware of that. I communicate with the Administrator, not sure who the DPCS is. I have never met them. Unless they were in the IDG. We have a large group. No, I dont think this Patient qualifies for hospice. I can see what happened with the previous team, we took over and this Patient is not a good eligible patient for hospice. Thats the situation its what it sounds like. This patient should not have been on hospice. Our team did not catch that." During a concurrent interview and record review on 2/27/2025 at 11:52 am with Director of Patient Care Services Designee (DPCSD), Patient 23s clinical record DPCSD stated, ";LCD guidelines indicate increased trips to ER- no, I dont think so. I dont think their condition warrants to go to ER. Respiratory failure, we dont have this diagnosis, our diagnosis is COPD, not correct for respiratory failure, no proof of this. Increasing physician home visits, no documented proof of this. Hypoxemia po2 55 mmHg means no oxygen, we dont have proof of this." During a concurrent interview and record review on 2/27/2025 at 12:07 pm with Director of Patient Care Services Designee (DPCSD), Patient 23s clinical record DPCSD stated," When enrolling in hospice we check for eligibility with insurance. Look for a referral and of course we talk to the primary care physician of the patient. I double checked hard file for Patient 23 and all uploaded clinical notes, there is no records in the patients files indicated frequent ER visits, increased physician home visits, any evidence of respiratory failure, or PO2 of less than or equal to 55 mmHg." A review of the agency's policy and procedure titled "Admission Criteria and Process", revised November 2020, the policy and procedure indicated, ";Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician." The policy and procedure further indicated, ";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, utilizing standard clinical prognosis criteria developed by LCD." During a review of the agencys policy and procedure (P&P) titled, Certification of Terminal Illness, revised November 2020, the P&P indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. During a review of the agencys P&P titled, Physician Services – Medical Director, revised November 2020, the P&P indicated that the purpose of the policy and procedure is to ensure qualified medical direction and consultation for the delivery of hospice services and programs. The P&P further indicated that the purpose of the policy and procedure is to demonstrate that the medical director/hospice team physician has overall responsibility for patient care through documentation that demonstrates interaction/communication with the attending physician as necessary for appropriate medical care.

Based on interview and record review, the hospice agency (agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Medical Director (MD) 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 patients clinical information necessary for initial certification and recertification of terminal illness for one of six sampled patients ( Patient 23). The deficient practice resulted in MD recertifying the patient for hospice care services without coordinating and verifying Patient 23's clinical information from the patient's primary physician. --- a. A review of Patient 23s Patient Face Sheet (admission information record) indicated a start of care (SOC) date of 10/18/2024, with a terminal diagnosis chronic obstructive pulmonary disease (COPD- A group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 23's Physicians Certification for Hospice Benefit, dated 10/18/2024 to 1/15/2025, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 23 had a life expectancy of six months or less if the terminal illness runs its normal course. The document indicated that Patient 23 was admitted with a terminal diagnosis of COPD. A review of Patient 23's Physicians Certification for Hospice Benefit, dated 1/16/2025 to 4/15/2025, benefit period #2, indicated the Physician 2 signed the attending physician referral section to indicate Patient 23 had a life expectancy of six months or less if the terminal illness runs its normal course. The document indicated that Patient 23 was admitted with a terminal diagnosis of COPD. A review of Patient 23s Referral Form, dated 10/16/2024, indicated the referring physician as Physician 4. A review of Patient 23s LCD Hospice Eligibility Determination (a tool used by the agency to help determine eligibility for hospice services), dated 1/13/2025, indicated that Patient 23 was not poorly or not responsive to bronchodilators which resulted in a loss of functional abilities resulting (the ability to perform daily tasks such as walking, dressing, showering). The document also indicated that Patient 23 had recent increasing emergency room visits, respiratory failure (a life threatening condition when not enough oxygen passes from your lungs to your blood), increased home visits by physician, and hypoxemia at rest on room air, as evidenced by pO2 < less than or equal to 55 mmHg (low levels of oxygen in your blood causing symptoms like headache, difficulty breathing, rapid heart rate and bluish skin, mmHg, millimeters of Mercury, unit of measurement used to calculate the oxygen pressure in blood). A review of Patient 23s Updated Assessment (an updated comprehensive assessment which was conducted by a registered nurse during recertification of hospice to include and support the current health status of the patient), dated 1/13/2025, indicated oxygen saturation (a measurement of the amount of oxygen found in blood) of 98 % (A normal level of oxygen is usually 95% or higher. Some people with chronic lung disease can have normal levels around 90%), on room air. During a joint home visit on 2/26/2025, at 12:30 p.m., with Licensed Vocational Nurse (LVN 1) at Patient 23s residence, Patient 23 was observed walking approximately 50 feet to unlock a security gate to let visiting team enter her living complex and then observed walking for about 50 feet back to her apartment. She was observed walking independently, without a walker. She walked without stopping to rest. She was able to speak during the ambulating, without any visible or audible signs of breathing difficulty. During an interview and observation on 2/26/2025 at 12:35 pm., Patient 23 stated that she learned about the hospice agency through a friend that had home care services. Patient stated that her friend received home care and that she thought she could benefit from it too. When asked who her primary care physician was, she stated Physician 3. States she does not know who Physician 4 is. She stated that she did not learn about the agency through her primary care physician (Physician 3), who has been her physician for a long time. Patient 23 stated that she has not had any emergency room visits in about a year or increased visits to a physician. She states that she remembers seeing her Physician 3 once in 2024. Patient 23 stated that her main health concern was stomach issues due to a gall bladder (a small, pear-shaped organ in the upper-right abdomen) surgery over a year ago. During an observation and interview on 2/26/2025 at 12:35 pm., LVN 1 was observed taking vital signs for Patient 23. Patient 23s was seated on the couch, breathing without any additional oxygen administration, breathing room air. Her heart rate was 68 (normal resting heart rate for adult ranges from 60 to 100 beats per minute), oxygen saturation (a measurement of the amount of oxygen found in blood) 94% (A normal level of oxygen is usually 95% or higher. Some people with chronic lung disease can have normal levels around 90%), Respiratory Rate (breathes taken per minute), 22 (normal respiratory rate for healthy adults is between 12–20 breaths per minute). The oxygen concentrator was observed to have an unused tubing in a bag attached to it. During an interview on 2/25/2025 at 12:59 pm., LVN 1 stated that Patient 23 does not need a walker or assistive device to walk. During an interview on 2/25/2025 at 1:35 pm., office staff (Staff 1) for Physician 3, stated that Patient 23 had visited Physician 3 on 10/17/2024 (one day before hospice admission). Staff 1 stated there was no record of Patient 23 needing hospice services or having a terminal diagnosis. During a record review of Patient 23s Physician Progress Notes, dated 10/17/2025, Physician 3 indicated that Patient 23s primary concern were lower back pain and knee issues. Physician 3 recorded respiratory rate of 16 with normal lung sounds. The document further indicated that the Patient 23s ability level to wash, shower, bathe and walk was ";easy" for her to perform. During a phone interview on 2/27/2025 at 9:45 am., with Patient 23s primary care physician (Physician 3), Physician 3 stated, ";I have been the seeing Patient 23 for a few years now. Last time she was in my office was October 17th, 2024. During that appointment we discussed referrals for orthopedics for a possible knee surgery and she was saying she has back pain too. As far as medical history, Patient 23 has chronic bilateral knee pain, but she doesnt use any assistive device for ambulation. She also has arthritic back pain. Other than that, she has hypertension and very well controlled COPD. I was unaware she is on hospice. Who signed her up for hospice?! She is not a hospice patient. She doesnt have any terminal conditions. She has pain and has drug seeking behavior. As you can see in my notes, I put no Soma or opiates. She had several incidents where she came in saying her purse got snatched and the opiates were inside, and she needed refills. Its never the laxatives or the blood pressure medications that go missing, its always the opiates. But this is definitely fraud, this patient is not a qualified hospice patient. No one has contacted me about her qualification, had they I would have told them just that. She has never had respiratory failure, and there is no record in here that she has had hospitalizations or ER visits. No record of home physician or telehealth visits. There is no documentation of a PO2 of less that 55 %. As far as needed assistance with ADLs, I have here that she can do ADLs with ease." During a phone interview on 2/27/2025 at 11:21 am with the current Medical Director of the hospice agency (Physician 5) Physician 5 stated, ";I have been with this agency for about 6 weeks, its basically a new team that we have. I am the medical director; I have been doing hospice for about 7 years." When asked how a patient is certified for hospice, MD stated, ";for me, first screen the patient, they come from referral, our job is to screen and make sure they are eligible, get the history and physical, then nurse does assessment, if we think they are 6 month or meet LCD criteria, for recertification, I do an actual visit, I go there. We havent come across that yet since Ive been here. I would communicate with the attending physician of the patient and make sure they are qualified. I would go over all documents that support the LCD criteria. KPS 40 usually when they are non-ambulatory. There is a list. We are usually looking for 50% or lower, unless terminal cancer. We use it for everyone as a rough guideline. We use it for criteria, it gives us an idea on their functional capacity, 40% is general non ambulatory, confusion also, level of disability, including ADLs, I have not seen Patient 23. I have not communicated with her attending physician. The office does that and if there are any updates they let me know. They are the central hub. I did not certify this patient. The previous doctor did. We do IDGs on Mondays. We did discuss this patient during IDGs, but I dont remember off the top of my head about this patient. I am not at a computer." Discussed observations of patient during home visit, Physician 5 stated, ";No that does not sound like a KPS 40 usually they are bed bound. Sounds like 60-70. Unfortunately, we just started with a new team. We are not aware of that. I communicate with the Administrator, not sure who the DPCS is. I have never met them. Unless they were in the IDG. We have a large group. No, I dont think this Patient qualifies for hospice. I can see what happened with the previous team, we took over and this Patient is not a good eligible patient for hospice. Thats the situation its what it sounds like. This patient should not have been on hospice. Our team did not catch that." During a concurrent interview and record review on 2/27/2025 at 11:52 am., with Director of Patient Care Services Designee (DPCSD), Patient 23s clinical record DPCSD stated, ";LCD guidelines indicate increased trips to ER- no, I dont think so. I dont think their condition warrants to go to ER. Respiratory failure, we dont have this diagnosis, our diagnosis is COPD, not correct for respiratory failure, no proof of this. Increasing physician home visits, no documented proof of this. Hypoxemia po2 55 mmHg means no oxygen, we dont have proof of this." During a concurrent interview and record review on 2/27/2025 at 12:07 pm with Director of Patient Care Services Designee (DPCSD), Patient 23s clinical record DPCSD stated," When enrolling in hospice we check for eligibility with insurance. Look for a referral and of course we talk to the primary care physician of the patient. I double checked hard file for Patient 23 and all uploaded clinical notes, there is no record in the patient's files indicated frequent ER visits, increased physician home visits, any evidence of respiratory failure, or PO2 of less than or equal to 55 mmHg." A review of the agency's policy and procedure titled "Admission Criteria and Process", revised November 2020, the policy and procedure indicated, ";Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician." The policy and procedure further indicated, ";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, utilizing standard clinical prognosis criteria developed by LCD." During a review of the agencys policy and procedure (P&P) titled, Certification of Terminal Illness, revised November 2020, the P&P indicated patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. During a review of the agencys P&P titled, Physician Services – Medical Director, revised November 2020, the P&P indicated that the purpose of the policy and procedure is to ensure qualified medical direction and consultation for the delivery of hospice services and programs. The P&P further indicated that the purpose of the policy and procedure is to demonstrate that the medical director/hospice team physician has overall responsibility for patient care through documentation that demonstrates interaction/communication with the attending physician as necessary for appropriate medical care.

Upon patient record review, 1 of 15 (Patient #2) did not have evidence that the hospice informed and provided written information to the patient concerning its policies on advance directives, including a description of applicable state law. Patient #2: This patient was assessed during the initial nursing assessment as alert and oriented x 2 with periods of confusion. They signed her own consents, however, the primary caregiver form was completed and signed by a "legal guardian". There initially was no documentation of this person being the guardian in the record. On the final day of survey, there was a "notarized" form stating patient was choosing this other individual as her legal guardian. It was signed by both parties and notarized. There still was no proof of court appointed guardianship, or that this form was filed with the court. In the notarized document it did state that the guardian would be responsible for signing all hospice consents, however, it also stated patient could rescind the guardianship at any time of her choosing. It was unclear as to who should be signing for patient.

Upon patient record review, 1 of 15 (Patient #2) did not have evidence that the hospice obtained the patient's or representative's signature confirming that they received a copy of the Patient's Rights and Responsibilities. Patient #2: This patient was assessed during the initial nursing assessment as alert and oriented x 2 with periods of confusion. They signed her own consents, however, the primary caregiver form was completed and signed by a "legal guardian". There initially was no documentation of this person being the guardian in the record. On the final day of survey, there was a "notarized" form stating patient was choosing this other individual as her legal guardian. It was signed by both parties and notarized. There still was no proof of court appointed guardianship, or that this form was filed with the court. In the notarized document it did state that the guardian would be responsible for signing all hospice consents, however, it also stated patient could rescind the guardianship at any time of her choosing. It was unclear as to who should be signing for patient.

Upon home visit observation, there was no evidence that the patient has the right: • To exercise his or her rights as a patient of the hospice • Have one's property and person treated with respect • To not be subjected to discrimination or reprisal for exercising his or her rights Patient visit #2: During the home visit, when interviewing the patient, who was alert and oriented x 4, she stated that she was not aware that she could choose her own physician.

Upon patient record review, 1 of 15 (Patient #2) did not have evidence that if a state court has not adjudged a patient incompetent, any legal representative designated by the patient in accordance with state law may exercise the patient's rights to the extent allowed by state law. Patient #2: This patient was assessed during the initial nursing assessment as alert and oriented x 2 with periods of confusion. They signed her own consents, however, the primary caregiver form was completed and signed by a "legal guardian". There initially was no documentation of this person being the guardian in the record. On the final day of survey, there was a "notarized" form stating patient was choosing this other individual as her legal guardian. It was signed by both parties and notarized. There still was no proof of court appointed guardianship, or that this form was filed with the court. In the notarized document it did state that the guardian would be responsible for signing all hospice consents, however, it also stated patient could rescind the guardianship at any time of her choosing. It was unclear as to who should be signing for patient.

Upon patient record review, 2 of 15 (Patient #1, 3) did not have evidence that the patient has received effective pain management and symptom control from the hospice for conditions related to the terminal illness. Patient #1: During home visit with surveyor, patient complained of pain of level 8. No interventions provided by RN during visit. No call to physician. No full pain assessment was completed. Patient #3: This patient was admitted on 10/03/24. During initial assessment he identified his pain threshold at a level 3. During that assessment he stated his pain was 8. RN documented he would take his current meds. 10/11/24, LVN documents pain as 7. They advised to give prn med, no visit for 7 days. 10/18/24 patient rates pain as 6, no visit for 6 days. 10/24/24, pt rates pain as 6, no visit for 8 days. 11/1/24, pt rates pain as level 7, full pain assessment not completed, no visit for 6 days. 11/7/24, pt rates pain as level 8, no visit 8 days. 11/15/24, pt rates pain at 7, no full pain assessment, no visit for 6 days. 11/21/24, pt rates pain at level 7, no visit for 13 days. 12/4/24, pt rates pain at 4 "all over". No pain assessment done no visit for 15 days. 12/19/24, pt rates pain at level 4, no pain assessment. 12/20/24, pt states "pain all over" no level of pain reported, no pain assessment completed, no visit for 12 days. 1/1/25, pt rates pain at 6. 01/02/25, patient rates pain at level 10. Also complained of burning on urination. UA sent stat. No visit for 7 days. 01/09/25, pt rates pain at 6. No complete pain assessment, No visit for 7 days. 01/16/25, pt rates pain at level 7, no MD, no visit for 18 days.

Upon patient record review, 1 of 15 (Patient #2) did not have evidence that the patient chooses a health care provider, including an attending physician. Patient #2: This patient was assessed during the initial nursing assessment as alert and oriented x 2 with periods of confusion. They signed her own consents, however, the primary caregiver form was completed and signed by a "legal guardian". There initially was no documentation of this person being the guardian in the record. On the final day of survey, there was a "notarized" form stating patient was choosing this other individual as her legal guardian. It was signed by both parties and notarized. There still was no proof of court appointed guardianship, or that this form was filed with the court. In the notarized document it did state that the guardian would be responsible for signing all hospice consents, however, it also stated patient could rescind the guardianship at any time of her choosing. It was unclear as to who should be signing for patient.

Upon patient record review, 2 of 15 (Patient #2) did not have evidence of the appropriate documentation for release of confidential information. Patient #2: This patient was assessed during the initial nursing assessment as alert and oriented x 2 with periods of confusion. They signed her own consents, however, the primary caregiver form was completed and signed by a "legal guardian". There initially was no documentation of this person being the guardian in the record. On the final day of survey, there was a "notarized" form stating patient was choosing this other individual as her legal guardian. It was signed by both parties and notarized. There still was no proof of court appointed guardianship, or that this form was filed with the court. In the notarized document it did state that the guardian would be responsible for signing all hospice consents, however, it also stated patient could rescind the guardianship at any time of her choosing. It was unclear as to who should be signing for patient.

Upon patient record review, 1 of 15 (Patient #2) did not have evidence that the patient received information about the services covered under the hospice benefit. Patient #2: This patient was assessed during the initial nursing assessment as alert and oriented x 2 with periods of confusion. They signed her own consents, however, the primary caregiver form was completed and signed by a "legal guardian". There initially was no documentation of this person being the guardian in the record. On the final day of survey, there was a "notarized" form stating patient was choosing this other individual as her legal guardian. It was signed by both parties and notarized. There still was no proof of court appointed guardianship, or that this form was filed with the court. In the notarized document it did state that the guardian would be responsible for signing all hospice consents, however, it also stated patient could rescind the guardianship at any time of her choosing. It was unclear as to who should be signing for patient.

Upon patient record review, 1 of 15 (Patient #2) did not have evidence that the patient received information about the scope of services that the hospice will provide and specific limitations on those services. Patient #2: This patient was assessed during the initial nursing assessment as alert and oriented x 2 with periods of confusion. They signed her own consents, however, the primary caregiver form was completed and signed by a "legal guardian". There initially was no documentation of this person being the guardian in the record. On the final day of survey, there was a "notarized" form stating patient was choosing this other individual as her legal guardian. It was signed by both parties and notarized. There still was no proof of court appointed guardianship, or that this form was filed with the court. In the notarized document it did state that the guardian would be responsible for signing all hospice consents, however, it also stated patient could rescind the guardianship at any time of her choosing. It was unclear as to who should be signing for patient.

Upon patient record review 1 of 15 (Patient #12) did not have evidence in the patient record that the hospice interdisciplinary group, in consultation with the individual's attending physician (if any), completed the comprehensive assessment no later than 5 calendar days after the election of hospice care. Patient #12: This patient was admitted 04/30/24. The initial psychosocial assessment was not completed until 06/01/24.

Upon patient record review 2 of 15 (Patient #12, 14) did not have evidence in the patient record that the comprehensive assessment identifies 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. Patient #12: This patient was admitted 04/30/24. There is no evidence in the chart of a spiritual care initial assessment. Patient #14: This patient was admitted 01/01/25. She died on day 6 (01/06/25) There is no evidence of an initial psychosocial assessment in the record. There is a visit in for the spiritual care, however, the visit is blank with no documentation completed.

Upon patient record review, 1 of 15 (Patient #12) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #12: This patients medication list included the following medications: Norco 5/325, 1 tablet every 6 hours prn. Hydrocodone/Acetaminophen 5/325, 1 tablet every 4 hours prn. hydrocodone Barbiturate/Acetaminophen 10/325, 1 tablet three times daily as needed. This is duplicate therapies.

Upon patient record review, 3 of 15 (Patient #1, 2, 9) did not have evidence in the patient record that the comprehensive assessment is updated including and by: • The hospice interdisciplinary group (in collaboration with the individual's attending physician, if any) • Changes that have taken place since the initial assessment • Information on the patient's progress toward desired outcomes • Reassessment of the patient's response to care • The assessment update must be accomplished as frequently as the condition of the patient requires, but no less frequently than every 15 days Patient #1: The orders for RN visits was written as one visit monthly with 3 prn. This does not meet the requirement of RN assessment updates no less frequently than 15 days. The patient had been seen by an RN on admit on 10/18/24. Subsequently, the RN visited 11/29 and 12/27 for assessment. There was no nursing visit with assessment from 12/27/24 until home visit with surveyor week of 2/3/25. Patient #2: The RN frequencies were written for one times monthly with 3 prn. This does not meet the requirement of RN assessment updates no less frequently than 15 days. The last RN visit with assessment was on December 13, 2024. Patient #9: The RN visited the patient 8/14/24 and not again until 09/11/24.

Condition of Participation: Interdisciplinary Group, Care Planning, and Coordination of Services. L536

Upon patient record review, 5 of 15 (Patient #1, 3, 4, 11, 12) did not have evidence that a Registered Nurse is designated to ensure continuous assessment of the patient and family's needs and to coordinate activities with other members of the interdisciplinary group (IDG). The IDG must work together and is responsible for supervision of the care and service for each patient and family. Patient #1: On 11/22/24, during a nursing visit, Phenergan was ordered for complaints of a cough. There was no follow up phone call or visit on this patient after new medication and complaint for 7 days. On 12/17/24, during a nursing visit, the patient stated she had a fall on 12/15/24. She stated she fell when walking outside as someone had tried to grab her bag. She had bruising across the bridge of her nose. No discussion of the incident or possible need for additional interventions/disciplines, no follow up phone call or visit for 7 days. Patient #3: This patient was admitted on 10/03/24. During initial assessment he identified his pain threshold at a level 3. During that assessment he stated his pain was 8. RN documented he would take his current meds. 10/11/24, LVN documents pain as 7. They advised to give prn med, no change in POC and no visit for 7 days. 10/18/24 patient rates pain as 6. , no visit for 6 days. 10/24/24, pt rates pain as 6. No change to POC no visit for 8 days. 11/1/24, pt rates pain as level 7, full pain assessment not completed, no visit for 6 days. 11/7/24, pt rates pain as level 8, no visit 8 days. 11/15/24, pt rates pain at 7, no full pain assessment, no visit for 6 days. 11/21/24, pt rates pain at level 7, no visit for 13 days. 12/4/24, pt rates pain at 4 "all over". No pain assessment done no visit for 15 days. 12/19/24, pt rates pain at level 4, no pain assessment, n. 12/20/24, pt states "pain all over" no level of pain reported, no pain assessment completed, no visit for 12 days. 1/1/25, pt rates pain at 6. 01/02/25, patient rates pain at level 10. Also complained of burning on urination. UA sent stat. No visit for 7 days. 01/09/25, pt rates pain at 6. No complete pain assessment, no visit for 7 days. 01/16/25, pt rates pain at level 7, no MD notification no visit for 18 days. Patient #4: On 10/02/24, patient called office and stated, "I want to die". No nurse visit made, no contact to MSW. Nurse saw patient 5 days later and MSW saw them 9 days later. No mention in either visit or notes regarding statement or assessment of patient for suicidal ideation or further explanation of concern. 01/07/25, visit for "flu" symptoms for 6 days. Pt started on Azithromycin and expectorant. No follow up call or visit for 6 days. On 01/13/25, another visit made to patient who continued with cough an congestion. Another order received for 2nd round of antibiotic. No follow up phone call or visit for 10 days. Patient #11: 05/16/24, patient called stating they had a "dental abscess" and requesting hospice MD write for antibiotics. Amoxicillin ordered, however, no nurse visit or assessment, and no visit 7 days. No mention of new medication or infection at that visit. Patient #12: on 06/18/24, Pt called complaining of "bleeding in throat". No visit done.

Upon patient record review, 1 of 15 (Patient #14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient #14: There is no POC with problems/goals/interventions for this patient regarding liver, cardiac, endocrine diseases along with other identified needs: pain, n/v, imminent death, funeral planning, coping of family, spiritual needs.

Upon patient record review, 4 of 15 (Patient #1, 3, 4, 11) did not have evidence that a revised plan of care includes information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care. Patient #1: No updates to POC after fall and possible mugging. No updates to POC after complaints of cough and addition of Phenergan. Patient #3: No changes to POC despite complaints of uncontrolled pain every visit. Patient #4: No changes to POC after initiation of antibiotics on 01/07/25 and 01/13/25 for suspected URI. Patient #11: 05/16/24, patient called stating they had a "dental abscess" and requesting hospice MD write for antibiotics. Amoxicillin ordered, however, no change to POC.

Upon client record review, 4 of 15 (Patient #1, 2, 4, 9) did not have evidence that the IDG ensures that the care and services are provided in accordance with the plan of care. Patient #1: RN ordered one time monthly which is not an allowable frequency for RN. No visit completed between 12/27 and week of 02/03/24 except for a supervised LVN visit on 01/27/25, however this visit did not include a nursing assessment. Patient #2: LVN visits were ordered 1 visit weekly and 3 prn. The patient was admitted on 10/04/24. The first LVN visit was made on 12/06/24. There was no LVN visit the week of 12/08/24. There was no LVN visit made the week of 12/29/24. The last visit made by an LVN was 01/05/25. There was an LVN visit in the record for 01/08/25, however this visit was empty with no content or signature. RN visits were ordered for once monthly. The RN visited four times in October without changes to frequency orders. The RN visited 5 times in November without order changes to frequencies. There were no visits made in the month of January and no changes to frequency orders. On 10/08/24, the SC saw the patient and the frequency orders were set at one SC visit monthly. No Further SC visits were made. Patient #4: The MSW orders were for MSW visit to patient monthly. The patient was admitted 06/05/24. There were no MSW visits in July of 24, September of 24, or January 25. The SC orders were for SC visits one monthly. There was no SC visit in July, August, October, and December of 24, or January of 25. Patient #9: MSW orders are written for once monthly. The patient was admitted on 08/01/24. The MSW saw the patient on 08/02/24. There were no further MSW visits made.

Upon patient client record review, 2 of 15 (Patient #2, 11) did not have evidence that each patient record contains: • Signed copies of the notice of patient rights in accordance with 418.52 • Signed election statement in accordance with 418.24 Patient #2: This patient was assessed during the initial nursing assessment as alert and oriented x 2 with periods of confusion. They signed her own consents, however, the primary caregiver form was completed and signed by a "legal guardian". There initially was no documentation of this person being the guardian in the record. On the final day of survey, there was a "notarized" form stating patient was choosing this other individual as her legal guardian. It was signed by both parties and notarized. There still was no proof of court appointed guardianship, or that this form was filed with the court. In the notarized document it did state that the guardian would be responsible for signing all hospice consents, however, it also stated patient could rescind the guardianship at any time of her choosing. It was unclear as to who should be signing for patient. Patient #11: The Hospice election statement did not include choice of physician, the election date was blank, the insurance (Medicare, Medicaid, other) was not checked, and it did not specify if the patient wanted an election addendum statement.

Upon patient client record review, 1 of 15 (Patient #9) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient #9: This patient was on service and discharged on 09/27/24. There was a discharge IDG meeting held on 09/27/24. All previous IDG notes for the patient's admission in hospice were present. There were subsequent IDG meetings held for this patient on 10/07/24, 10/21/24, 11/04/24, 11/18/24, and 12/02/24. Each of these had individual discipline notes in and were signed by the RN and physician, despite the fact that the patient had been discharged. On 02/03/25, there is a communication note entry stating the DPCS called the patient to assess for volunteer needs. It states they "declined volunteer". The patient had been discharged from service 4 months prior.

Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Conditions of Participation (the terms healthcare organizations must meet in order to participate in federally funded healthcare programs) regarding Patients Rights was met as follows. --- 1. The HA failed to ensure patients' rights to be informed of the services the HA provides and the limitations of these services for two out of 14 sampled patients (Patient 1, and Patient 5) certified to receive hospice care and services. (Refer to L 519). The cumulative effect of this systemic practice resulted in the failure of the hospice agency to deliver statutorily (written law) mandated Federal (government) compliance for Patients Rights to ensure their rights were not violated and patients received quality hospice care and services.

Based on observation, interview, and record review, the Hospice Agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure patients rights to be informed of the services the HA provides and the limitations of these services for two out of 14 sampled patients (Patients 1 and 5) certified to receive hospice care and services. This deficient practice resulted in the patients' rights being violated for not being fully informed about the purpose of the hospice care services and its limitations. --- a. A review of Patient 1s admission record indicated a start of care (SOC) date of 8/28/2023, with a terminal diagnosis of senile degeneration (older individuals who suffered from cognitive decline, particularly memory loss). A review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG, a team responsible for the holistic care of the hospice beneficiary) form, dated 12/29/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one to two visit per week, registered nurse (RN) to conduct initial evaluation within five days of admission then every recertification. During a joint home visit on 1/17/2024, at 12 p.m., with LVN 2 at Patient 1s residence, Patient 1 was observed washing the dishes and walking steadily at the dining room without using an assistive device. During an interview on 1/17/2024, at 12:30 p.m., with FM 1 (family member), when FM 1 was asked if Patient 1 and the family were informed about the purpose of the hospice care services and FM 1 stated a nurse from the agency would come visit every week to take her blood pressure readings. FM 1 also stated Patient 1 had no attending physician and FM 1 referred her to the hospice agency. FM 1 further stated that the agency offered to provide free medical supplies such as lotions, incontinent pads and shampoo upon patient admission to their hospice service. b. A review of Patient 5's admission record indicated an SOC date of 11/23/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 5's Plan of Care/Interdisciplinary Group form, dated 12/22/2023, indicated the frequency of visits of licensed vocational nurse (LVN) to one to two visit per week, to conduct initial evaluation within five days of admission then every recertification. During an interview on 1/17/2024, at 2 p.m., during a phone interview with FM 2, when she was asked if the hospice agency informed the patient and family members about the purpose of the hospice care services, she stated the hospice service will provide a nurse to visit every week to take his blood pressure and provide him with his prescribed medications. FM 2 also stated that Patient 5 was not sick and will be dying in six months, and that a family friend referred Patient 1 to the hospice agency. During an interview with the director of patient care services (DPCS) on 1/18/2024, at 1 p.m., she stated the visiting nurse should have informed the patient regarding hospice services upon their admission. A review of the agencys undated policy and procedure titled, ";Patient Bill of Rights/Responsibilities", indicated each patient will be an active, informed participant in his/her plan of care. The Patient Bill of Rights/Responsibilities statement defines the right of the patient to be informed in advance of service about the care to be furnished, the organizations scope of services, services under the Medicare Hospice Benefit and any limitations on these services.

Based on observation, interview and record review, the hospice agency (HA, an agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid programs [a joint federal and state program that helps cover medical costs for some people with limited income and resources] regarding Initial and Comprehensive Assessment of Patients was met as followed. --- Findings: 1. The HA failed to conduct an comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), and identified care and services for 2 of 14 sampled patients (Patient 2 and 11). This deficient practice had the potential to delay the delivery of the patient's individualized plan of care. (Refer to L 524). 2. The HA failed to review all medications the patients were taking and update the medication profiles with the currently used medications for 2 of 14 sampled patients (Patients 2 and Patient 11). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reaction that could be life threatening. (Refer to L530). 3. The HA failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status, and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness for five out of 14 sampled patients (Patient 1, Patient 2, Patient 5, Patient 6, and Patient 10). (Refer to 532). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily (written rules or law) mandated compliance with Federal (government) regulation for Initial and Comprehensive Assessment of Patient to ensure the provision of quality healthcare are being provided to patients certified to receive the hospice benefits.

Based on observation, interview, and record review, the hospice agency (HA) failed to conduct an accurate comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), and identified the care and services for 2 of 14 sampled patients (Patient 2 and 11). This deficient practice had the potential to delay the delivery of Patient 2 and Patient 11 individualized plan of care. --- 1. During a review of Patient 2's Patient Face Sheet (admission information) indicated Patient 2 had a start of care (SOC) of 12/8/2023 with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of coronary artery disease (a type of heart disease where the arteries of the heart cannot deliver enough oxygen-rich blood to the heart), hyperlipidemia (condition in which there are high levels of fat particles (lipids) in the blood), difficulty walking, impaired balance, unsteady gait, and needs assistive device for ambulation. During a review of Patient 2's Interdisciplinary (IDT) Plan of Care and Review of the Comprehensive Assessment dated 12/22/2023 indicated continue to monitor physical dynamic status such as vital signs, nutrition, hydration, elimination, pain, skin status, and psychosocial status. Patient 2's Interdisciplinary (IDT) Plan of Care and Review of the Comprehensive Assessment indicated that medication reviewed and care plan established and reviewed with the family. A home visit was conducted on 1/17/2024 at 11:20 a.m., at Patient 2s residential senior home apartment with the licensed vocational nurse 1 (LVN 1). During a joint home visit on 1/17/2024 at 11:30 a.m., with LVN 1, observed Patient 2 in the bedroom, alert to name, person and place, on his bed, not in any respiratory distress noted. Patient 2 complained of 9/10 (a pain scale tool use numbers from 0 to 10, a score of 0 means no pain, and 10 means the worst pain you have ever known) neck pain radiating to his right shoulder. Patient 2 denied nausea or vomiting. Patient 2 verbalized, "I am mentally stable but physically incapable because of this terrible pain." Patient 2 stated that he stumbled and fell on the pavement hitting his head. Patient stated he went to the emergency room back on 7/3/2023 to 7/5/2023. Patient 2 stated that he reported and complained to the hospice nurse of pain on the neck, but did not have any new pain medication. 2. . During a review of Patient 11's Patient Face Sheet indicated Patient 11 had a start of care (SOC) of 12/1/2023 with a terminal diagnosis of chronic congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply) and essential hypertension (high blood pressure). A review of the Patient 11's Interdisciplinary Plan of Care and Review of the Comprehensive Assessment dated 12/1/2023, indicated continue to monitor physical dynamic status such as vital signs, nutrition, hydration, elimination, pain, skin status, and psychosocial status. Patient 11's Interdisciplinary Plan of Care and Review of the Comprehensive Assessment indicated, the medication reviewed and care plan established and reviewed with the family. A review of Patient 11's Initial Orders and Plan of Care dated 12/1/2023 for the benefit period 12/1/2023 to 2/28/2024, indicated skilled nursing (SN) visits once a week for the first week and one as needed visit for pain and symptom management, nursing assessment of patient and patient caregiver needs, development of patient and patient caregiver care plan/intervention in collaboration with IDT, administer and educate on medication and evaluation of patient and caregiver response to treatment. A joint home visit was conducted on 1/17/2024 at 9:45 a.m., at Patient 11s residential senior home apartment with the Administrator/Director of Nursing (Admin/DON). Patient 11 was in bed room. During an observation of the home visit with the Admin/DON, Patient 11 was hard of hearing, had problems with vision, requires assistance in bed and chair, showed periods of forgetfulness, able to verbalize needs. Patient 11 complained of pain on his left leg 5/10 , left chest and constant pain on the right big toe. During the observation, Patient 11 was observed with a red mark on the tip of the right big toe no bigger than a dime. A review of Patient 11 Nursing Clinical Note dated 12/1/2023 indicated that Patient 11 was non-responsive and legally blind, hard of hearing/deaf. On the narrative, skilled nurse documented Patient 11 was alert and oriented to name, place, and time, situation and current events during the assessment was done, comfortable able to make needs known but with episodes of forgetfulness. There was no documentation that Patient 11's was assessed for the redness of the right big toe and for the pain of left leg. During an interview with the Admin/DON at 1/17/2024 on 10:30 a.m., Admin/DON stated that the Patient 11 would be referred to a podiatrist to check the toes. Admin stated that the chest pain may be pleuritic pain (a condition in which the pleura [two large, thin layers of tissue that separate your lungs from your chest wall] becomes inflamed). Admin/DON, stated that it has been a while since he conducted a home visit and he was mostly in the office to monitor the operations of the agency. During an interview on 1/18/2024 at 11:00 a.m., with the Registered Nurse Supervisor (RNS) stated that visiting nurses including admitting and LVNs should know how to conduct a head to toe assessment during the admission and every home visit. RNS stated that the visiting nurse should had assessed Patient 2's complained of neck pain and Patient 11's complained of pain on the left leg and right big toe. A review of the HA's policy titled "Initial Assessment" revised 4/2020 indicated Admitting registered nurse uses an assessment scale/rating tool to assess for problems and to establish a baseline status of each symptom rated. The nurse will immediately notify the Clinical Supervisor or designee regarding the need for medical consultation and problems encountered. An attempt will be made by the Clinical Supervisor or designee to contact the patient's physician. If the Clinical Supervisor or designee is unable to contact patient's physician, the Clinical Supervisor or designee will notify the hospice's Medical Director of the change in patient condition and the inability to contact patient's physician to request medical consultation. A review of the HA's policy titled "Ongoing Assessments" revised 4/2020 indicated During each home visit, the Case Manager or other discipline will evaluate the patient according to the problems identified during the initial assessment and thereafter the comprehensive assessment. The nurse will assess each patient on each visit, for:A. Pain, including the origin, location, duration, severity, and relief measures B. Secondary symptoms related to the terminal illness such as, nausea, vomiting, and respiratory distress, and patient's response to medications and other interventions C. Factors that alleviate or exacerbate physical symptoms D. Current treatment related to the identified symptoms and the patient's response E. Vital signs appropriate to the patient's condition F. Breath sounds G. Skin integrity H. Bowel sounds, elimination ( urinary and bowel) I. Mental status J. Appetite/diet, nutritional status K. Functional status L. Safety/home environment

Based on observation, interview, and record review the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to review all medications the patients were taking and update the medication profiles with the current medications for two of 14 sampled patients (Patients 2 and Patient 11). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reaction that could be life threatening. --- a. During a review of Patient 2's Patient Face Sheet (admission information) form indicated Patient 2 start of care (SOC) date of 12/8/2023 with a terminal diagnosis (an advanced stage of a disease with an unfavorable prognosis and no known cure) of coronary artery disease (a type of heart disease where the arteries of the heart cannot deliver enough oxygen-rich blood to the heart), hyperlipidemia (condition in which there are high levels of fat particles (lipids) in the blood), presents with pain on bilateral lower extremities, unsteady gait, and needs assistive device for ambulation. During a review of Patient 2's "Interdisciplinary Plan of Care and Review of the Comprehensive Assessment" dated 12/22/2023 indicated, continue to monitor physical dynamic status such as vital signs, nutrition, hydration, elimination, pain, skin status, and psychosocial status. Patient 2's "Interdisciplinary Plan of Care and Review of the Comprehensive Assessment" indicated, medication reviewed and care plan established and reviewed with the family. Patient 2's "Interdisciplinary Plan of Care and Review of the Comprehensive Assessment" indicated issues for next Interdisciplinary Group (IDG) as follows: Review/Evaluation of the Plan of Care and discussion any change of patient condition, monitor for decline in condition, provide symptoms management, pain control and comfort measures. During a joint home visit on 1/17/2024 at 11:20 a.m., at Patient 2s residential senior home apartment with the licensed vocational nurse 1 (LVN 1), LVN 1 reviewed Patient 2's medication profile. During a review of Patient 2's medication profile with LVN 1 on 1/17/2024 at 11:20 a.m., and an interview with Patient 2's family member, Patient 2's family member, stated all the medication listed on Patient 2's medication profile, Patient 2 were not currently taking. Patient 2's family member stated that Patient 2 was taking only the Tylenol 500 milligrams (mg, unit of measurement) from the medication profile. A review Patient 2's medication profile indicated the following list of medication that Patient 2 were not taking. 1. Tylenol 500 mg every 6 hours for mild pain 2. Robaxin 750 mg every 8 hours as needed for neck pain 3. Losartan 50 mg daily for blood pressure4. Vitamin D3 50 microgram (mcg) daily vitamin D supplement 5. Cod liver oil caps 300 mg daily (supplement)6. Meclizine 12.5mg 2x a week as needed for dizziness7. Aspirin (ASA) 81 mg daily8. Ibuprofen 600 mg every 6 hours prn for mod to severe pain but the bottle was missing. b. During a review of Patient 11's Patient Face Sheet form indicated Patient 11's SOC of 12/1/2023 with a terminal diagnosis of chronic congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply) and essential hypertension (high blood pressure that is not due to another medical condition). A review of the HA's document titled "Interdisciplinary Plan of Care and Review of the Comprehensive Assessment" dated 12/1/2023, indicated continue to monitor physical dynamic status such as vital signs, nutrition, hydration, elimination, pain, skin status, and psychosocial status. Patient 11's "Interdisciplinary Plan of Care and Review of the Comprehensive Assessment" indicated medication reviewed and care plan established and reviewed with the family and next IDG: Review/Evaluation of the Plan of Care and discussion any change of patient condition, monitor for decline in condition, provide symptoms management, pain control and comfort measures. During a home visit conducted on 1/17/2024 at 9:45 a.m., at Patient 11s residential care facility with the Administrator/Director of Nursing (Admin/DON), Admin/DON reviewed Patient 11's medication profile. During a review of Patient 11 medication profile, the following were discrepancies were identified. 1. Famotidine suspension (liquid form) on the agency's medication profile, but in the medication available was in a tablet form. The residential care facility administrator (RCA) stated that the pharmacy was sending the famotidine tablet.2. Tylenol 325 mg as needed on medication profile, and in the facility the medication frequency was listed to be administered every 6 hours as needed During an interview with the Admin/DON on 1/17/2024 at 11:00 a.m., Admin/DON stated that the HA visiting nurse should always conduct a medication reconciliation, comparing the bottles or bubble packs with the facility and the medication list. During an interview with the Registered Nurse Supervisor (RNS) on 1/18/2024 at 11:00 a.m., RNS stated that the skilled nurse should verify the medications every home visit by comparing the patients medication bottles to the medication profile from admission. RNS stated that every change in medication, doses or frequency, the nurse should call the office and verify it with the doctor and update the medication profile in the chart. A review of the HA's policy titled " Medication Profile" revised 4/2020, indicated that Patients receiving medications administered by the organization will have a current, accurate medication profile in the clinical record. The medication profiles will be updated for each change to reflect current medications, and new and/or discontinued medications. Upon admission to hospice, the admitting nurse will initiate a medication profile to document the current medication regimen, including name, dose, strength, route, frequency, date and time of administration. If the patient is enrolled in Medicare Part D, the nurse will review the medications with the patient or their representative and determine the relationship of the medication to the patient's terminal illness and related conditions that contribute to the terminal prognosis. A drug regimen review will be performed by a registered nurse at the time of initial and comprehensive assessment, when updates to the comprehensive assessments are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication.

Based on observation, interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to conduct and document an accurate comprehensive assessment that reflected the patient's current health status, and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness (a disease or condition due to which a patient's death is anticipated in six months) for five out of 14 sampled patients (Patient 1, Patient 2, Patient 5, Patient 6 and Patient 10). This deficient practice resulted in patients admitted for hospice care were not appropriately evaluated by the health care professionals and certified to receive the benefits. --- 1. During a review of Patient 2's face sheet indicated patient is an 82 year old male patient had a start of care (SOC) of 12/8/2023 with a terminal diagnosis of coronary artery disease (a type of heart disease where the arteries of the heart cannot deliver enough oxygen-rich blood to the heart), comorbidities are hyperlipidemia ( high cholesterol), hypertension (high blood pressure), headache with hallucination (perceiving things that are not heard or seen), urgency (urinary frequency), insomnia (inability to sleep), risk for fall, vision deficit, hard of hearing, urinary incontinence, forgetful, presents with pain on bilateral lower extremities, fatigue with activity, generalized muscle weakness, , difficulty walking, impaired balance, unsteady gait, and needs assistive device for ambulation. A review of the HA's document titled " IDT(Interdisciplinary Plan of Care and Review of the Comprehensive Assessment" for dated 12/8/2023 indicated skilled nurse (SN) continue to observe and assess all bodily systems focusing on cardiac and muscular system. Will continue to monitor physical dynamic status such as vital signs, nutrition, hydration, elimination, pain, skin status and psychosocial status. ISSUES FOR NEXT IDG: Review/Evaluation of the Plan of Care and discussion any change of patient condition. Monitor for decline in condition Provide symptoms management, pain control and comfort measures. A review of the HA's document titled " Initial Orders and Plan of Care" for the certification period of 12/8/2023 to 3/6/2024 indicated on 12/8/2023, 12/22/2023 the patient was not referred for Physical Therapy evaluation and treatment, Social worker , volunteer services and spiritual care visit indicated was declined. A home visit was conducted on 1/17/2024 at 11:20 a.m., at Patient 2s residential senior home apartment with the licensed vocational nurse 1 (LVN 1). Granddaughter opened the door. During an interview with the granddaughter on 1/17/2024 at 11:20 a.m., granddaughter stated that she does not understand how hospice works. Granddaughter stated that the patient does not seem dying and stated "What he needs is to see a brain doctor. He fell and suffered a big bump, had partial vision and is in a lot of pain." Granddaughter stated that they were not offered a hospital bed and the agency promised to send an oxygen machine but it was not delivered. Granddaughter stated the social worker came once but I really did not understand because she was speaking mostly to my grandfather." Granddaughter also stated that now he is weak and unable to drive, I leave him alone to get groceries and other stuff and I am scared that he would fall. When asked if he was offered volunteer services , granddaughter said " No, I don't know what that mean." During an interview with the Licensed Vocational Nurse 1 (LVN1) at the home visit on 1/17/2024 stated "I will give her this website that she can look into, it is called "Mexican-American Foundation" they offer resources for people if they need anything from food stamps to questions with benefits. I use them also to ask questions. They don't get any other information, they just need your name and the address." 2. A review of Patient 10's face sheet indicated an SOC date of 12/31/2023 with the diagnosis of malignant neoplasm of the colon (cancer of the colon). A review of the HA's document titled " IDT Plan of Care and Review pf Comprehensive Assessment" dated 1/5/2024 indicated INITIAL IDT MEETING: Initial RN assessment completed. Explanation of hospice benefits and services to patient and family member. Discussed hospice services including medications, equipment, hospice physician's home visit and all other IDG members. Discussed patient's medical condition with the IDG members via phone conference and presented patient's medical condition to have met hospice admission criteria. Primary care physician for the 1st 60 days benefit period. Medication reviewed and care plan established and reviewed with the family. ISSUES FOR NEXT IDG: Review/Evaluation of the Plan of Care and discussion any change of patient condition Monitor for decline in condition Provide symptom management, pain control and comfort measures Spiritual services, social worker and volunteer services was declined. During a telephone interview with Patient 10's caregiver/wife on 1/18/2024 at 2:00 p.m., stated 2 people came to her home and referred her to this agency. Wife stated that he is still able to go to the bathroom without assistance. Wife stated that the nurse only comes once a month and the patients doctor is different from the doctors listed on Patient 10's face sheet. Wife stated that a woman came to their home and referred them to the hospice agency. Wife stated that she does not know how hospice works and that she wants to be referred to a social worker to know more about their benefits. Wife stated that they were not referred to a social worker. Wife stated that the patient still goes to his doctors every three months and she drives him to these appointments. Wife stated the patient had shingles( causes a painful rash that may appear as a stripe of blisters on the trunk of the body. Pain can persist even after the rash is gone (this is called postherpetic neuralgia).Treatments include pain relief and antiviral medications such as acyclovir or valacyclovir. Wife further stated patient's doctor prescribed a cream that they cannot afford and pain medication every 6 hours as needed. A review of the HA's policy titled "Initial Assessment" revised 4/2020 indicated An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care unless otherwise specified by the physician, patient or representative to be completed in less than 48 hours. 1. Admitting registered nurse will gather the following information:A. Start of care dateB. Certification periodC. Patient diagnosis and other pertinent diagnosisD. Patient demographicsE. AllergiesF. Medications: dose/frequency/routeG. Orders for specific hospice services and disciplines, treatments and procedures(amount/frequency/duration)H. Equipment needs and supplyI. End-of-life preferences2. Admitting registered nurse uses an assessment scale/rating tool to assess for problems and to establish a baseline status of each symptom rated. Items assessed may include, but are not limited to, the following:A. Pain assessmentB. Vital signsC. Fatigue, drowsiness D. Nausea, appetiteE. Depression, anxietyF. Shortness of breathG. Well-being, spiritual needs 3. Admitting registered nurse will determine the patient's and caregiver's primary concern, goals and immediate care needs.4. Admitting nurse will assign the patient a risk categorization for the emergency management plan.5. Admitting registered nurse will document interventions and teaching performed.6. Admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during this initial assessment.A. Nursing and bereavement sections will always be identified7. Based on the initial assessment, the plan of care will be initiated on the day of admission.8. The initial assessment will be filed in the patient's clinical record.9. If the comprehensive assessment is completed during the admission visit, the initial assessment will be included as a part of the comprehensive assessment. a. A review of Patient 1s admission record indicated a start of care (SOC) date of 8/28/23, with a terminal diagnosis of senile degeneration (older individuals who suffered from cognitive decline, particularly memory loss). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 8/28/23 to 11/25/23, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit on 1/17/24, at 12 p.m., with LVN 2 at Patient 1s residence, Patient 1 was observed washing the dishes and walking steadily at the dining room without using an assistive device. During an interview on 1/17/24, at 12:30 p.m., with FM 1 (family member), when FM 1 was asked if Patient 1 and the family were informed about the purpose of the hospice care services and FM 1 stated a nurse from the agency would come visit every week to take her blood pressure readings. FM 1 also stated Patient 1 had no attending physician and FM 1 referred her to the hospice agency. FM 1 further stated that the agency offered to provide free medical supplies such as lotions, incontinent pads and shampoo upon patient admission to their hospice service. b. A review of Patient 5's admission record indicated an SOC date of 11/23/23, with a terminal diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 5's Physicians Certification for Hospice Benefit, dated 11/23/23 to 2/20/24, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During an interview on 1/17/24, at 2 p.m., during a phone interview with FM 2, when she was asked if the hospice agency informed the patient and family members about the purpose of the hospice care services, she stated the hospice service will provide a nurse to visit every week to take his blood pressure and provide him with his prescribed medications. FM 2 also stated that Patient 5 was not sick and will be dying in six months, and that a family friend referred Patient 1 to the hospice agency. c. A review of Patient 6's admission record indicated an SOC date of 11/28/23, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other other mental functions). A review of Patient 6's Physicians Certification for Hospice Benefit, dated 11/28/23 to 2/25/24, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. On 1/18/24, at 11:30 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital from where the patient gets discharged. On 1/18/24, at 12:30 p.m., during a phone interview with Physician 1, Physician 1 stated that he was not the attending physician, and did not know who the attending physicians were for Patients 1, 2, 5, 6 and 10. Physician 1 stated since Patients 1, 2, 5,6 and 10 were admitted for hospice service, he now becomes the patient's attending physician, signed the referral attending physician section because no one would sign it. Physician 1 further stated that she determined the patients' eligibility for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician.

Based on observation, interview, and record review, the Hospice Agency failed to ensure the Condition of Participation for Medical Director was met as evidenced by: --- 1. The hospice agency failed to ensure the Medical Director and/or physician designee conducted an assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services for five out of 14 sampled patients (Patient 1, Patient 2, Patient 5, Patient 6 and Patient 10). (Refer to L667) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutory mandated (state law) compliance with Federal regulation for Medical Director services to ensure highest quality of patient care was provided to the patients certified to receive hospice services.

Based on observation, interview and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Medical Director and/or physician designee conducted an assessment, review, and verification of the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (a hospice physician narrative designed to explain the clinical findings that support a life expectancy of six months or less), to qualify for hospice care and services (health care that focuses on the palliation to ease the symptoms without curing the underlying disease of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) for five of 14 sampled patients (Patient 1, Patient 2, Patient 5, Patient 6 and Patient 10). This deficient practice resulted in the Medical Director certifying these patients without clinical documentation to receive the hospice benefits. --- a. A review of Patient 1s admission record indicated a start of care (SOC) date of 8/28/2023, with a terminal diagnosis of senile degeneration (older individuals who suffered from cognitive decline, particularly memory loss). A review of Patient 1's Physicians Certification for Hospice Benefit, dated 8/28/2023 to 11/25/2023, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 1 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During a joint home visit on 1/17/2024, at 12 p.m., with Licensed Vocational Nurse 2 (LVN 2) at Patient 1s residence, Patient 1 was observed washing the dishes and walking steadily at the dining room without using an assistive device (Devices-e.g. cane, use by disable person to help to perform particular task). During an interview on 1/17/2024, at 12:30 p.m., with FM 1 (family member), when FM 1 was asked if Patient 1 and the family were informed about the purpose of the hospice care services and FM 1 stated a nurse from the agency would come visit every week to take her blood pressure readings. FM 1 also stated Patient 1 had no attending physician and FM 1 referred her to the hospice agency. FM 1 further stated that the agency offered to provide free medical supplies such as lotions, incontinent pads and shampoo upon patient admission to their hospice service. b. During a review of Patient 2's face sheet indicated patient is an 82 year old male patient had a start of care (SOC) of 12/8/2023 with a terminal diagnosis of coronary artery disease (a type of heart disease where the arteries of the heart cannot deliver enough oxygen-rich blood to the heart), comorbidities are hyperlipidemia ( high cholesterol), hypertension (high blood pressure), headache with hallucination (perceiving things that are not heard or seen), urgency (urinary frequency), insomnia (inability to sleep), risk for fall, vision deficit, hard of hearing, urinary incontinence, forgetful, presents with pain on bilateral lower extremities, fatigue with activity, generalized muscle weakness, , difficulty walking, impaired balance, unsteady gait, and needs assistive device for ambulation. A review of Patient 2's (IDT)-Interdisciplinary Plan of Care and Review of the Comprehensive Assessment for dated 12/8/2023 indicated skilled nurse (SN) continue to observe and assess all bodily systems focusing on cardiac and muscular system. Will continue to monitor physical dynamic status such as vital signs, nutrition, hydration, elimination, pain, skin status and psychosocial status. ISSUES FOR NEXT IDG: Review/Evaluation of the Plan of Care and discussion any change of patient condition. Monitor for decline in condition Provide symptoms management, pain control and comfort measures. A review of Patient 2's Initial Orders and Plan of Care for the certification period of 12/8/2023 to 3/6/2024 indicated on 12/8/2023, 12/22/2023 the patient was not referred for Physical Therapy evaluation and treatment, Social worker , volunteer services and spiritual care visit indicated was declined. A home visit was conducted on 1/17/2024 at 11:20 a.m., at Patient 2s residential senior home apartment with the licensed vocational nurse 1 (LVN 1). Granddaughter opened the door. During an interview with the granddaughter on 1/17/2024 at 11:20 a.m., granddaughter stated that she does not understand how hospice works. Granddaughter stated that the patient does not seem dying and stated "What he needs is to see a brain doctor. He fell and suffered a big bump, had partial vision and is in a lot of pain." Granddaughter stated that they were not offered a hospital bed and the agency promised to send an oxygen machine but it was not delivered. Granddaughter stated the social worker came once but I really did not understand because she was speaking mostly to my grandfather." Granddaughter also stated that now he is weak and unable to drive, I leave him alone to get groceries and other stuff and I am scared that he would fall. When asked if he was offered volunteer services , granddaughter said " No, I don't know what that mean." During an interview with the Licensed Vocational Nurse 1 (LVN1) at the home visit on 1/17/2024 stated "I will give her this website that she can look into, it is called "Mexican-American Foundation" they offer resources for people if they need anything from food stamps to questions with benefits. I use them also to ask questions. They don't get any other information, they just need your name and the address." c. A review of Patient 5's admission record indicated an SOC date of 11/23/2023, with a terminal diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 5's Physicians Certification for Hospice Benefit, dated 11/23/2023 to 2/20/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 5 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. During an interview on 1/17/2024, at 2 p.m., during a phone interview with Family Member 2 ( FM 2), when she was asked if the hospice agency informed the patient and family members about the purpose of the hospice care services, she stated the hospice service will provide a nurse to visit every week to take his blood pressure and provide him with his prescribed medications. FM 2 also stated that Patient 5 was not sick and will not be dying in six months, and that a family friend referred Patient 5 to the hospice agency. d. A review of Patient 6's admission record indicated an SOC date of 11/28/2023, with a terminal diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other other mental functions). A review of Patient 6's Physicians Certification for Hospice Benefit, dated 11/28/2023 to 2/25/2024, benefit period #1, indicated the Physician 1 signed the attending physician referral section to indicate Patient 6 had a life expectancy of six months or less if the terminal illness runs its normal course. There was no documented evidence of a comprehensive assessment that was conducted in coordination with the patient's primary physician that included laboratory test results, imaging data, history and physical, and biopsy results showing evidence to support the terminal illness diagnosis. e. A review of Patient 10's face sheet indicated an SOC date of 12/31/2023 with the diagnosis of malignant neoplasm of the colon (cancer of the colon). A review of Patient 10's (IDT) -Interdisciplinary Plan of Care and Review of Comprehensive Assessment dated 1/5/2024 indicated INITIAL IDT MEETING: Initial RN assessment completed. Explanation of hospice benefits and services to patient and family member. Discussed hospice services including medications, equipment, hospice physician's home visit and all other IDG members. Discussed patient's medical condition with the IDG members via phone conference and presented patient's medical condition to have met hospice admission criteria. Primary care physician for the 1st 60 days benefit period. Medication reviewed and care plan established and reviewed with the family. ISSUES FOR NEXT IDG: Review/Evaluation of the Plan of Care and discussion any change of patient condition Monitor for decline in condition Provide symptom management, pain control and comfort measures Spiritual services, social worker and volunteer services was declined. During a telephone interview with Patient 10's caregiver/wife on 1/18/2024 at 2:00 p.m., stated two people came to her home and referred her to this agency. Wife stated that he is still able to go to the bathroom without assistance. Wife stated that the nurse only comes once a month and the patients doctor is different from the doctors listed on Patient 10's face sheet. Wife stated that a woman came to their home and referred them to the hospice agency. Wife stated that she does not know how hospice works and that she wants to be referred to a social worker to know more about their benefits. Wife stated that they were not referred to a social worker. Wife stated that the patient still goes to his doctors every three months and she drives him to these appointments. Wife stated the patient had shingles( causes a painful rash that may appear as a stripe of blisters on the trunk of the body, and the patient's doctor prescribed a cream that they cannot afford and pain medication every 6 hours as needed. On 1/18/2024, at 11:30 a.m., during an interview with the Director of Patient Care Services (DPCS), the DPCS stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician, if not a referral from a social worker or a physician from the hospital from where the patient gets discharged. On 1/18/2024, at 12:30 p.m., during a phone interview with Physician 1, Physician 1 stated that he was not the attending physician, and did not know who the attending physicians were for Patients 1,Patient 2, Patient 5, Patient 6 and Patient 10. Physician 1 stated since Patients 1, Patient 2, Patient 5,Patient 6 and Patient 10 were admitted for hospice service, he now becomes the patient's attending physician, she signed the referral attending physician section because no one would sign it. Physician 1 further stated that she determined the patients' eligibility for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patients. A review of the HA's policy titled "Initial Assessment" revised 4/2020 indicated An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care unless otherwise specified by the physician, patient or representative to be completed in less than 48 hours. 1. Admitting registered nurse will gather the following information:A. Start of care dateB. Certification periodC. Patient diagnosis and other pertinent diagnosisD. Patient demographicsE. AllergiesF. Medications: dose/frequency/routeG. Orders for specific hospice services and disciplines, treatments and procedures(amount/frequency/duration)H. Equipment needs and supplyI. End-of-life preferences2. Admitting registered nurse uses an assessment scale/rating tool to assess for problems and to establish a baseline status of each symptom rated. Items assessed may include, but are not limited to, the following:A. Pain assessmentB. Vital signsC. Fatigue, drowsiness D. Nausea, appetiteE. Depression, anxietyF. Shortness of breathG. Well-being, spiritual needs 3. Admitting registered nurse will determine the patient's and caregiver's primary concern, goals and immediate care needs.4. Admitting nurse will assign the patient a risk categorization for the emergency management plan.5. Admitting registered nurse will document interventions and teaching performed.6. Admitting registered nurse will determine the other disciplines to complete the appropriate sections of the comprehensive assessment based on identified problems and needs during this initial assessment.A. Nursing and bereavement sections will always be identified7. Based on the initial assessment, the plan of care will be initiated on the day of admission.8. The initial assessment will be filed in the patient's clinical record.9. If the comprehensive assessment is completed during the admission visit, the initial assessment will be included as a part of the comprehensive assessment. A review of the agency's undated policy and procedure titled "Admission Criteria and Process", indicated Hospice will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting illness and prognosis of 6 months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (LCDs). Hospice will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. During a review of the agencys undated policy and procedure titled ";Physician Services-Medical Director", indicated the hospice Medical Director will have overall responsibility for the medical component of the hospice program. The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group, assuring continuity of hospice medical services, and assuring appropriate measures to control patient symptoms. The duties and responsibilities of the Medical Director will include, but not limited to reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care.

Upon patient record review, 2 of 5 (Patient #3, #5) did not have evidence in the patient record that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. Patient #3: Order for oxygen PRN is not listed on medication list. Corrected on site. Patient #5: Order for oxygen PRN is not listed on medication list. Corrected on site.

Upon patient record review, 1 of 5 (Patient #5) did not have evidence in the patient record that the interdisciplinary group, as part of the review of the plan of care, determines the ability of the patient and/or family to safely self-administer drugs and biologicals to the patient in his or her home. If the patient and/or family are not capable of safely administering drugs and biologicals in the home, the hospice must address this issue in the patient's plan of care. Patient #5 There was no documented evidence that patient/familys ability to safely administer medication was assessed.