Every finding on record at Devina Hospice Care Inc

Based on observation, interview, and record review, the hospice agency (HA) failed to accurately assess the patient's eligibility (the quality or state of being eligible) for hospice services related to the palliation and management of the terminal illness (an illness or condition which cannot be cured and is likely to lead to someone's death) and related conditions for one of 8 sampled patients (Patient 14). This deficient practice had the potential to result in the misuse of the provision of the hospice services benefits that could affect the patients highest practicable mental, physical, and psychosocial well-being and its quality of life. --- A review of Patient 14's clinical record indicated a start of care (SOC) date of 2/24/2022, with diagnosis that included heart disease (refers to several types of heart conditions). A review of Patient 14's "Physician Certification for Hospice Benefit" Certification period number 3, from 8/23/2022 to 10/21/2022, indicated Patient 14's terminal diagnosis was heart disease. There was no documented evidence the hospice's Medical Director communicated with the primary physician to certify Patient 14 had a life expectancy of six months or less if the terminal illness runs its normal course. A review of Patient 14's undated "LCD Hospice Eligibility Determination" (LCD - provides guidance in determining medical necessity of services) indicated Patient 14 was qualified to receive hospice services based on the "Yes" answer provided for "Untreatable Condition: Has patient declined surgical procedures?; Does this CHF (Chronic Heart Failure, a chronic condition in which the heart doesn't pump blood as well as it should) or angina (chest pain). Patient 14 met the criteria for NYHA (New York Heart Association, classification that provides a simple way of classifying the extent of heart failure) Class IV (a stage in heart failure that has severe limitations, experiences symptoms even while at rest) level. During an interview on 10/19/2022 at 3:25 p.m., Patient 14 stated she had never declined any surgical procedures because no physicians had informed her she needed one. During an interview with RN Supervisor (RN 1) on 10/20/2022 at 11:20 a.m., RN 1 stated the HA did not have any documented evidence regarding Patient 14 declining any surgical procedure related to her terminal diagnosis. RN 1also stated he had confirmed with Patient 14 through interview that no physicians had advised her of any surgical procedures related to her heart disease diagnosis. A review of Patient 14's Comprehensive Nursing Assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), done by the Registered Nurse (RN), dated 2/24/2022, indicated Patient 14 was alert and oriented, and ambulatory with cane. Per Comprehensive Nursing Assessment, Patient 14 had KPS of 50 (Karnofsky Performance Scale, which allows patients to be classified as to their functional impairment), PPS of 50 (Palliative Performance Scale, a valid, reliable functional assessment tool), and NYHA class IV. The HA was not able to provide documented evidence showing Patient 14 had a NYHA class IV heart failure. During an interview with RN 1 on 10/20/2022 at 11:20 a.m., RN 1 stated the HA did not have any documented evidence that Patient 14 had a NYHA Class IV heart failure. RN 1 also stated the Comprehensive Nursing Assessment for Patient 14 indicated ";mild dyspnea with exertion," while NYHA Class IV required patient to have symptoms of heart failure at rest, not with exertion. A review of the HAs Plan of Correction, completed on 10/3/2022, indicated ";As a corrective action, the agency adopted LCD assessment sheets and sent out an RN supervisory nurse to see all active patients to assess for eligibility to hospice services. The agency ensured there was documented evidence of meeting LCD guidelines. The agency ensured all CTls (certification of terminal illness) were completed and there was documented evidence of support for clinical findings supporting the physician CTl narrative."

Based on observation, interview, and record review the Hospice Agency (HA) failed to provide education on administration of oxygen therapy to one of 8 sampled patients, (Patient 14). Patient 14 did not receive the amount of oxygen ordered by the physician. This failure had the potential to result in patient getting adverse effects from receiving inappropriate oxygen flow. --- A review of Patient 14's clinical record indicated a start of care (SOC) date of 2/24/2022, with diagnosis that included heart disease (refers to several types of heart conditions). A review of Patient 14s ";Current Treatment/Medication/DME List" indicated Patient 14 had an order for oxygen inhalation at 2 liters per minute via nasal cannula as needed. During a joint home visit with Licensed Vocational Nurse (LVN 1) on 10/19/2022 at 11 a.m., Patient 14 stated her nostrils were irritated and dry from using the oxygen. Upon observation, it was noted the oxygen concentrator was set to deliver 5 liters of oxygen per minute. During an interview with Patient 14 on 10/19/2022 at 11:20 a.m., she stated she did not remember if she changed the oxygen setting. She also stated she did not know oxygen was considered a medication and had to be administered in the exact amount as ordered by the physician. During an interview with LVN 1 on 10/19/2022 at 11:25 a.m., LVN 1 stated, ";Just like medication, oxygen could have side effects if not following MD order." LVN 1 also stated she would educate Patient 14 regarding oxygen therapy, including the correct amount to administer and possible side effects. During an interview with RN Supervisor (RN 1) on 10/20/2022 at 11:20 a.m., RN 1 stated oxygen needed to be treated as a medication. He stated, ";Patient needs to be on 2 liters of oxygen per minute, not 5 liters per minute, because thats what the doctor has ordered." RN 1 further stated if patient had shortness of breath that was not relieved with 2 liters per minute of oxygen, then the physician would need to be notified so that patient could be re-evaluated. A review of the HAs undated policy, titled ";Administration of Oxygen Therapy and Home Safety," indicated, ";The hospice nurse is responsible for ensuring that oxygen is administered as prescribed, as well as for evaluating the patients response to therapy."

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the comfort pack contained all the medications as listed in medication list for one of 8 sampled patients, (Patient 14). This deficient practice placed the patient at risk of discomfort during end-of-life moment due to unavailability of comfort kit item when needed. --- A review of Patient 14's clinical record indicated a start of care (SOC) date of 2/24/2022, with diagnosis that included heart disease (refers to several types of heart conditions). A review of Patient 14's "Physician Certification for Hospice Benefit" Certification period 3 from 8/23/2022 to 10/21/2022, indicated Patient 14's terminal diagnosis was heart disease, unspecified. A review of Patient 14s ";Current Treatment/Medication/DME List" indicated Patient 14 had an order for a comfort pack which contained the following medications: - Acephen 650 mg (milligrams), 5 suppositories, 1 suppository every 4 hours as needed (medicine for pain and fever) - Dulcolax 10 mg, 5 suppositories, 1 suppository once daily as needed (medicine for constipation) - Levsin 0.125 mg, 6 tablets, 1 tablet every 6 hours as needed (medicine for increased oral secretions) - Morphine Sulfate 20 mg /ml, 0.25 Ml sublingual every 2 hours as needed (medicine for severe pain) During a joint home visit with Licensed Vocational Nurse (LVN 1) on 10/19/2022 at 11 a.m., Levsin 0.125 mg, 6 tablets, were not included in Patient 14s comfort kit. During an interview with LVN 1 on 10/19/2022 at 11:45 a.m., LVN 1 stated Levsin 0.125 mg should be available in Patient 14s comfort kit. LVN 1 stated it was very important patient remained comfortable while enrolled as a hospice patient. During an interview with RN Supervisor (RN 1) on 10/20/2022 at 11:20 a.m., RN 1 stated it was the visiting nurses responsibility to check patients medications at home and compare it with the medication list/profile with every visit, including medications which were part of the comfort kit. Per RN 1, the visiting nurse needs to check patients medications in case there were expired medications, missing medications, new medications, or discontinued medications. RN 1 stated the HA did not have a policy regarding comfort kit/pack as of 10/20/2022.

Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure, one of 8 sampled patients, (Patient 14), had the written plan of care (POC) available at the patients residence that indicates the care and services being rendered by the HA. This failure had the potential to result in placing the patient at risk for not receiving the services/care stated in their individualized POC. --- A review of Patient 14's clinical record indicated a start of care (SOC) date of 2/24/2022, with diagnosis that included heart disease (refers to several types of heart conditions). A review of Patient 14s Plan of Care (POC)/Interdisciplinary Group (IDG) Review, dated 10/10/2022 indicated Patient 14 was scheduled to Skilled Nursing (SN) visits once a week, Medical Social Worker (MSW) and Spiritual Counselor (SC) visits every recertification, Registered Nurse (RN) every 14 days for supervisory visits and ongoing comprehensive assessment, volunteer services once per month, Hospice Aide services were offered but declined. During a joint home visit with Licensed Vocational Nurse (LVN 1) on 10/19/2022 at 11 a.m., POC was not available in Patient 14s hospice home binder. During an interview with LVN 1 on 10/19/2022 at 11:57 a.m., LVN 1 stated ";The Plan of Care is supposed to be inside the binder. It is important the patient and her family or caregiver could review it, so that they could participate in her care." A review of facilitys policy titled, ";The Plan of Care," revised April 2016, indicated ";As needed, the patient and family/caregiver will receive written instructions regarding treatments or aspects of care that will be the responsibility of the patient and family/caregiver to provide or follow through with."

Based on interview and record review, the hospice agency (HA) failed to ensure the emergency preparedness plan/drill for field staff were completed in an annual basis. This failure had the potential for the staff to lack the knowledge to respond effectively during an emergency/disaster situation. Findings: During a review of the emergency preparedness plan of the HA, on 9/12/22 at 2:00 p.m., the HA did not have evidence of Emergency Preparedness training/disaster drill for all field staff. During an interview with the Director of Patient Care Services (DPCS), on 9/12/2022 at 2:10 p.m., she could not provide evidence of the field staff receiving Emergency Preparedness training/disaster drill training. A review of the agency's policy and procedure titled "Emergency Management Plan", revised April 2017, indicated the organization will comply with all applicable Federal, State, and local emergency preparedness requirements and will establish and maintain an emergency preparedness program that meets those regulations. Devina Hospice Care, Inc will test the emergency management plan, at each site included in the plan, at least annually, either in response to an actual emergency or in a planned exercise.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Initial and Comprehensive Assessment was met as follws: 1. The HA failed to accurately assessed the patient's eligibility for hospice services related to the palliation and management of the terminal illness and related conditions for eleven of 13 sampled patients (Patient 2, 3, 4, 5, 6, 7, 8,10, 11, 12 and 13). (Refer to L521) 2. The HA failed to ensure comprehensive assessment including vital signs, height, weight, and oxygen saturation (the fraction of oxygen-saturated hemoglobin relative to total hemoglobin in the blood- normal pulse oximeter readings usually range from 95 to 100 percent) was conducted to the patients for 8 of 13 sampled patients (Patient 4, 5, 6, 7, 8, 10, 11 and 12). (Refer to L524) 3. The HA staff failed to ensure one of 13 sampled patients (Patient 3) had home medications listed in the medication profile. (Refer to L530) 4. The HA failed to provide initial bereavement assessments for eight of 13 sampled patients (Patients 1, 4, 6, 7, 10, 11, 12 and 13). (Refer to L531) The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with the Initial and Comprehensive Assessment of Patient to ensure highest quality of care are provided to the patients assessed for eligibility to receive hospice care and services.

Based on observation, interview, and record review, the hospice agency (HA) failed to accurately assessed the patient's eligibility for hospice services related to the palliation and management of the terminal illness and related conditions for eleven of 13 sampled patients (Patient 2, 3, 4, 5, 6, 7, 8, 10, 11, 12 and 13). This deficient practice has the potential risk to result in the misuse of the hospice provision of services that could result to a substandard provision of patient care. Findings: h. A review of Patient 10's admission record indicated the patient was admitted to the HA on 1/07/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated skilled nurse (SN) visits once per week and once per week as needed and change of condition for assessment and comfort monitoring, the spiritual counselor (SC) and medical social worker (MSW) to do assessment within 5 days from SOC (start of care), certification & as needed. The hospice aide (HA) and volunteer visit were declined. On 9/07/2022, at 11:25 a.m., a joint home visit was made for Patient 10 with the Registered Nurse (RN 1) at the patient's residence. Patient 10 was not at home. Several phone calls were made to Patient 10's three phone number listed on her clinical records, but calls have either no dial tone and/or went straight to voicemail. At 11:35 a.m., during an interview, RN 1 stated she does not know where Patient 10 was located. A review of the form of "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" of Pulmonary Disease dated 1/12/2022, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 10 had a disabling dyspnea (shortness of breath) at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat (Oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95-100%) less than or equal to 88% determined by O2 sat monitors. A review of Patient 10's clinical record indicated there was no documented evidence Patient 10 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators or had O2 saturation of 88% or less. During an interview with the DPCS on 9/12/2022, at 2:35 p.m., she stated she was not able to find the documented evidence Patient 10 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators or had O2 saturation less than or equal to 88%. i. A review of Patient 11's admission record indicated the patient was admitted to the HA on 10/17/2021, with diagnosis of heart disease, unspecified (a type of disease that affects the heart or blood vessels). A review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated the registered nurse visit once every 2 weeks and as needed, and the licensed vocational nurse visit of once a week and one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of the form of "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" of Heart Disease dated 10/31/2021 and 2/02/2022, indicated section 1 - "Untreatable Condition", and section 2 - New York Heart Association (NYHA) Classification" must be met. It was mark "yes" in section 1 that Patient 11 has been ruled out as a candidate for surgical procedure. Section 2 was mark "yes" that Patient 11 met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). A review of Patient 11s clinical record indicated no documented evidence Patient 11 was ruled out as a candidate for surgical procedure related to heart disease. There was no documented evidence Patient 11 was on complete rest, confined to bed and chair, any physical activity brings on discomfort and symptoms occurs at rest. During a phone interview with Patient 11, on 9/12/2022 at 10:30 a.m., Patient 11 stated he was not aware of any surgical procedure about his heart, and he was doing okay. He stated he has mild symptoms when he went out for a walk but has no symptoms if he was in bed or chair. Patient 11 stated nobody told him that he has life expectancy of 6 months or less. During an interview with the DPCS on 9/12/2022, at 2:35 p.m., she stated she was not able to find the documented evidence Patient 11 was ruled out as a candidate for a surgical procedure related to heart disease or had symptoms of heart disease even when patient was at rest. j. A review of patient 12's admission record indicated the patient was admitted to the HA on 6/27/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 12's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated skilled nurse (SN) visits once per week and one as needed. The hospice aide (HA), MSW, SC, and volunteer service were declined. On 9/08/2022, at 2:55 p.m., a home visit was conducted for Patient 12. Patient 12 was observed awake, alert, ambulatory, not on oxygen and not showing any signs and symptoms of pulmonary disease. Patient 12 stated he walks to the market everyday several blocks away from where he lives and does not have shortness of breath. Patient 12 stated he was diagnosed with COPD since 2010, takes his medication/inhalers daily and is not going to die within 6 months. A review of the form of "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" of Pulmonary Disease dated 6/27/2022, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 12 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat less than or equal to 88% determined by O2 sat monitors. A review of Patient 12's clinical record indicated there was no documented evidence Patient 12 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators and had O2 saturation of 88% or less. During an interview with the DPCS on 9/12/2022, at 2:35 p.m., she stated she was not able to find the documented evidence Patient 12 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators or had O2 saturation less than or equal to 88%. k. A review of Patient 13's admission record indicated the patient was admitted to the HA on 6/28/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 13's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated RN visits once every two weeks plus one visit as needed, and LVN visit once a week plus one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of the form of "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" of Pulmonary Disease, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 13 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat less than or equal to 88% determined by O2 sat monitors. A review of Patient 13's clinical record indicated there was no documented evidence Patient 13 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators and had O2 saturation of 88% or less. During an interview with the DPCS on 9/12/2022, at 2:35 p.m., she stated she was not able to find the documented evidence Patient 13 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators or had O2 saturation less than or equal to 88%. A review of the agency's policy and procedure titled, "Admission Criteria and Process", revised April 2017, indicated, "Devina Hospice Care, Inc will admit any patient with a life-limiting illness that meets the admission criteria. The patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs)".

e. A review of Patient 10's admission record indicated the patient was admitted to the HA on 1/07/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated skilled nurse (SN) visits once per week and once per week as needed and change of condition for assessment and comfort monitoring, the spiritual counselor (SC) and medical social worker (MSW) to do assessment within 5 days from SOC (start of care), certification & as needed. The hospice aide (HA) and volunteer visit were declined. A review of Patient 10's Comprehensive Nursing Recertification (Re-cert) Assessment, dated 7/05/2022, indicated the spaces for blood pressure, temperature, pulse, respiration, oxygen saturation, height and weight were blank. f. A review of Patient 11's admission record indicated the patient was admitted to the HA on 10/17/2021, with diagnosis of heart disease, unspecified (a type of disease that affects the heart or blood vessels). A review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated the registered nurse visit once every 2 weeks and as needed, and the licensed vocational nurse visit of once a week and one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of Patient 11's Comprehensive Nursing Recertification Assessment, dated 6/10/2022, indicated the spaces for blood pressure, temperature, pulse, respiration, and oxygen saturation were blank. A review of Patient 11's Comprehensive Nursing Recertification Assessment, dated 8/09/2022, indicated the spaces for blood pressure, temperature, pulse, and respiration were blank. g. A review of patient 12's admission record indicated the patient was admitted to the HA on 6/27/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 12's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated skilled nurse (SN) visits once per week and one as needed. The hospice aide (HA), MSW, SC, and volunteer service were declined. A review of Patient 12's Comprehensive Nursing Assessment, dated 6/27/2022, indicated the spaces for height and weight were blank. During a concurrent interview and record review with the Case Auditor (LVN 1), on 9/12/2022 at 2:15 p.m., LVN 1 stated nursing assessment should be accurate and complete. LVN 1 stated Patient 10, 11 and 12's comprehensive assessment were incomplete.

Based on interview and record review, the hospice agency (HA) failed to provide initial bereavement assessments for eight of 13 sampled patients (Patients 1, 4, 5, 6, 10, 11, 12 and 13). This deficient practice had the potential to impact a family members' abilities to cope with the patients' death. Findings: e. A review of Patient 10's admission record indicated the patient was admitted to the HA on 1/07/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 1/17/2022, indicated skilled nurse (SN) visits once per week and once per week as needed and change of condition for assessment and comfort monitoring, the spiritual counselor (SC) and medical social worker (MSW) to do assessment within 5 days from SOC (start of care), certification & as needed. The hospice aide (HA) and volunteer visit were declined. The POC indicated the goal of bereavement was for the caregiver and family will be able to access bereavement services to aid with their anticipatory grief within 5 days from SOC. The intervention was for the bereavement counselor (BC) to visit caregiver and family within 5 days from SOC for bereavement initial assessment. A review of Patient 10's clinical record indicated that there was no initial bereavement assessment conducted. f. A review of Patient 11's admission record indicated the patient was admitted to the HA on 10/17/2021, with diagnosis of heart disease, unspecified (a type of disease that affects the heart or blood vessels). A review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 5/09/2022, indicated the registered nurse visit once every 2 weeks and as needed, and the licensed vocational nurse visit of once a week and one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. The POC indicated the goal of bereavement was for the mother and family will be able to access bereavement services to aid with their anticipatory grief within 5 days from SOC. The intervention was for the bereavement counselor (BC) to visit mother and family within 5 days from SOC for bereavement initial assessment. A review of Patient 11's clinical record indicated that there was no initial bereavement assessment conducted. g. A review of Patient 12's admission record indicated the patient was admitted to the HA on 6/27/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 12's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated skilled nurse (SN) frequency of visits of once per week and one as needed. The hospice aide (HA), MSW, SC, and volunteer service were declined. A review of Patient 12's clinical record indicated that there was no initial bereavement assessment conducted. h. A review of Patient 13's admission record indicated the patient was admitted to the HA on 6/28/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 13's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated RN frequency of visits to once every two weeks plus one visit as needed, and LVN visit to once a week plus one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of patient 13's clinical record indicated that there was no initial bereavement assessment conducted. On 9/09/2022 @ 1:10pm, during an interview with the Spiritual Counselor (SC), he stated as a bereavement coordinator each patient should have a plan of care for bereavement to prepare the family for grieving. SC stated 99% of the time he will document on the patient's clinical record on the day he did the assessment. When asked why several patients have no initial bereavement assessment within 5 days of SOC, SC stated it does not mean he did not do the assessment. He stated he was just late in his documentation. During an interview with the Director of Patient Care Services (DPCS), on 9/12/2022, at 2:35 p.m., she stated that a bereavement assessment should be conducted on admission. The DPCS further stated that Patients 1,4, 5, 6, 10, 11, 12 and 13 did not have an initial bereavement assessment conducted on admission. A review of the agency's policy and procedure titled "Bereavement Assessment," revised April 2017, indicated on admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that will be given to the Bereavement Coordinator. The Bereavement Coordinator will review the bereavement risk assessment and will develop a plan for intervention based on the findings on the bereavement follow-up assessment and input from interdisciplinary group members. All bereavement documentation will be submitted for filing in the patient's permanent clinical record.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met by failing to: 1. Ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were held by all the members of interdisciplinary group to discuss the patient's comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process, ongoing assessments and care planning process for four of 13 sampled patients, (Patients 3, 5, 12 and 13). (Refer to L541) 2. Ensure a care plan (a process of identifying patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) was developed for the respiratory system that included problems, interventions and goals, for a patient who had a diagnosis of chronic obstructive pulmonary disease (COPD, a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible) for one of 13 sampled patients, (Patient 6). (Refer to L545) 3. Ensure the oxygen concentrator (a medical device that gives extra oxygen) was available for the patients, who have chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe) and with physician order for oxygen therapy, for two of 13 sampled patients (Patient 3 and 5). (Refer to L550) 4. Ensure the IDG including the Medical Director had communicated with the patients' primary physician to verify the patient's eligibility for hospice care services for 11 of 13 sampled patients (Patient 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13). (Refer to L554) 5. Ensure care and services were being provided in accordance with the Plan of Care for seven of 13 sampled patients (Patient 2, 3, 5, 6, 7, 12 and 13). (Refer to L555) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services.

Based on interview and record review, the hospice agency (HA) failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings were held by all the members of interdisciplinary group to discuss the patient's comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process, ongoing assessments and care planning process for four of 13 sampled patients, (Patients 3, 5, 12 and 13). This deficient practice has a potential for the patient's progress or decline will not be identified by the IDG, interventions will not be implemented, and patient care goals will not be achieved. Findings: a. A review of Patient 3's clinical record indicated a start of care (SOC) date of 12/22/2020, with a primary diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 3's Plan of Care (POC, documents the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers)/Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), dated 8/1/2022, indicated skilled nurse (SN) frequency of visits of once per week and one as needed, Hospice Aide once per week, Social Worker (MSW) and Spiritual Counsellor (SC) on initial comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process), recertification, and as needed. Volunteer service was declined. A review of Patient 3's "POC/IDG Review" dated 7/5/2022, 7/18/2022, and 8/1/2022, indicated the spaces for MSW signature were left blank. A review of the "IDG Log" dated 7/5/2022, 7/18/22, and 8/1/2022 indicated there was no MSW signature. During an interview with the Director of Patient Care Services (DPCS), on 9/12/2022, at 2:35 p.m., she stated that the IDG team meeting should be held every two weeks with participation of all the IDG members (Medical doctor, DPCS, SN, MSW and spiritual counselor) even though the patient had refused any of above service. She stated when the IDG members participated in the IDG meeting, they should have signed right away. The DPCS was not able to provide the documented evidence all the IDG members had participated in the IDG meeting for 7/5/2022, 7/18/2022, and 8/1/2022. c. A review of Patient 5's clinical record indicated Patient 5 started hospice care on 12/28/21, with a terminal diagnosis of COPD. It indicated the Medical Director was the referring/attending/patient choice doctor. A review of the POC/IDG Review dated 12/28/2021 indicated Registered Nurse (RN) visits were for initial assessment, supervisory visit and ongoing comprehensive assessment, recertification and as needed. The SN visit was once a week and as needed. The MSW visit was to be on initial assessment, on certification, and as needed. The hospice aide (HA) service and the volunteer service was offered but declined. A review of the "POC/IDG Review" dated 7/5/2022, 7/18/22, 8/1/2022, 8/15/2022, 8/29/2022 indicated the spaces of signature for the social worker, were blank. A review of the "IDG Log" dated 7/5/2022, 7/18/22, 8/1/2022, 8/15/2022, 8/29/2022 did not indicate signatures of the social worker. During an interview with the DPCS on 9/12/2022, at 3 p.m., she was not able to provide the documented evidence that the social worker had participated in the POC/IDG meetings. d. A review of Patient 12's clinical record indicated the patient was admitted to the HA on 6/27/2022, with diagnosis of unspecified COPD. A review of Patient 12's POC/IDG, dated 7/05/2022, SN frequency of visits of once per week and one as needed. The HA, MSW, SC, and volunteer service were declined. A review of Patient 12's POC/IDG meeting record indicated blank spaces, no signatures to indicate the Medical MSW had participated the meetings on 7/05/2022, 7/18/2022/, 8/01/2022 and 8/15/2022. e. A review of Patient 13's clinical record indicated the patient was admitted to the HA on 6/28/2022, with diagnosis of unspecified COPD. A review of Patient 13's POC/IDG, dated 7/05/2022, indicated RN frequency of visits to once every two weeks plus one visit as needed, and LVN visit to once a week plus one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of Patient 13's POC/IDG meeting record indicated blank spaces, no signatures to indicate the MSW had participated the meetings on 7/05/2022, 7/18/2022/, 8/01/2022, 8/15/2022 and 8/29/2022. During an interview with the DPCS, on 9/12/2022, at 2:35 p.m., she stated that the IDG team meeting should be held every two weeks with participation of all the IDG members (Medical doctor, DPCS, SN, MSW and spiritual counselor) even though the patient had refused any of above service. She stated when the IDG members participated in the IDG meeting, they should have signed right away. The DPCS was not able to provide the documented evidence that all the IDG members had participated in the IDG meeting for Patient 12 and 13 on the above days. A review of the agency's policy and procedure titled "Interdisciplinary Group Meeting," revised April 2017, indicated the interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care. Each patient's plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patient's condition requires. Members of the interdisciplinary group meeting will sign an attendance from that will be kept by the hospice Clinical Supervisor/Nursing Supervisor. A review of the agency's policy titled, "Interdisciplinary Group Coordination of Care" revised in April 2017, indicated the care will be provided by an interdisciplinary group made up of physicians, nurses, social workers, certified hospice aides, homemakers, clergy, counselors, volunteers, and therapists. The interdisciplinary group (in collaboration with the attending physician, if, any) will conduct assessment, develop and update the plan of care, and review the effectiveness of care at minimum of every two (2) weeks.

f. A review of Patient 12's clinical record indicated the patient was admitted to the HA on 6/27/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 12's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated skilled nurse (SN) frequency of visits of once per week and one as needed to assess cardiac, neurological and sensory status, to teach patient on safe transfer techniques, and to assess and monitor effectiveness of medications, pain and severity, and nutritional needs every visit. A review of Patient 12's history of SN visits for August 2022 indicated there was no recorded visits or notes from the Skilled nurse from the week starting 8/14/2022 to 8/20/2022. During a concurrent interview and record review with the Case Auditor (LVN 1), on 9/12/2022 at 2:15 p.m., LVN 1 stated SN visits for Patient 12 was once a week. LVN 1 was unable to provide the SN visit notes or documented evidence Patient 12 or his family and/or caregiver refused SN visit from 8/14/2022 to 8/20/2022. g. A review of Patient 13's clinical record indicated the patient was admitted to the HA on 6/28/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 13's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated RN frequency of visits to once every two weeks plus one visit as needed, and LVN visit to once a week plus one visit as needed to assess and monitor effectiveness of medications, oxygen saturation, cardiac status, and nutritional needs every visit. A review of Patient 13's history of SN visits for July 2022 and August 2022 indicated there was no recorded visits or notes from the Skilled nurse from the week starting 7/31/2022 to 8/06/2022. During a concurrent interview and record review with the Case Auditor (LVN 1), on 9/12/2022 at 2:15 p.m., LVN 1 stated SN visits for Patient 13 was once a week. LVN 1 stated she was unable to provide the SN visit notes or documented evidence Patient 13 or his family and/or caregiver refused SN visit from 7/31/2022 to 8/06/2022. A review of the agency's policy and procedure titled, "The Plan of Care", revised April 2017, indicated the care provided to the patient must be in accordance with the plan of care.

e. A review of Patient 11's admission record indicated the patient was admitted to the HA on 10/17/2021, with diagnosis of heart disease, unspecified (a type of disease that affects the heart or blood vessels). A review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated the registered nurse visit once every 2 weeks and as needed, and the licensed vocational nurse visit of once a week and one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of Patient 11's Psychosocial Assessment indicated no documentation was done and/or completed. f. A review of patient 12's admission record indicated the patient was admitted to the HA on 6/27/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 12's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated skilled nurse (SN) visits once per week and one as needed. The hospice aide (HA), MSW, SC, and volunteer service were declined. A review of Patient 12's Psychosocial Assessment indicated no documentation was done and/or completed. g. A review of Patient 13's admission record indicated the patient was admitted to the HA on 6/28/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 13's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated RN visits once every two weeks plus one visit as needed, and LVN visit once a week plus one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of Patient 13's Psychosocial Assessment indicated no documentation was done and/or completed. A review of the agency's policy and procedure titled "Comprehensive Assessment", revised April 2017, indicated a comprehensive patient assessment will be performed by the hospice IDG (Interdisciplinary Group) no later than 5 calendar days after the election of hospice care in consultation with attending physician. All baseline data and other relevant information will be documented in the patient's clinical record, including the patient's psychosocial status, including emotional barriers to treatment, cognitive limitations, memory and orientation, family relationships, social history, source, and adequacy of environmental and other resources, coping mechanisms and the patient's and family/caregiver's reaction to illness. A review of the agency's policy and procedure titled "Psychosocial Services", revised April 2017, Indicated the social worker will contribute to the comprehensive assessment and ongoing update to the comprehensive assessment based on the needs of the patient. Psychosocial assessments will be performed on each new hospice admission.

No Findings have been entered by Surveyor as of 9/22/22 at 4:55 p.m (Sonia Richard)

h. A review of Patient 10's admission record indicated the patient was admitted to the HA on 1/07/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Patient 10's admission information sheet (face sheet) indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated skilled nurse (SN) visits once per week and once per week as needed and change of condition for assessment and comfort monitoring, the spiritual counselor (SC) and medical social worker (MSW) to do assessment within 5 days from SOC (start of care), certification & as needed. The hospice aide (HA) and volunteer visit were declined. A review of the "Physician's Certification for Hospice Benefit (the patient must be certified as being terminally ill to receive hospice care)" from 1/07/2022 to 4/06/2022, signed by the Medical Director who was also the referring doctor, indicated "It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice". It also indicated Patient 10 meets LCD (Local Coverage Determination-determining Terminal Status) medical guidelines to receive hospice services. A review of the form "LCD Hospice Eligibility Determination" of Pulmonary Disease dated 7/05/2022, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 10 had a disabling dyspnea (shortness of breath) at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat (Oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95-100%) less than or equal to 88% determined by O2 sat monitors. A review of Patient 10's clinical record indicated there was no documented evidence Patient 10 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators and/or had O2 saturation of 88% or less. A review of Patient 10's Comprehensive Nursing Assessment, dated 1/07/2022, indicated Patient 10 was awake, alert, oriented and verbally responsive. Patient 10 was ambulatory with steady gait and able to perform ADLs (or activities of daily living, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) independently. Patient 10's oxygen saturation was 92% in room air and has regular heart sounds. The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." On 9/07/2022, at 11:25 a.m., a joint home visit was made for Patient 10 with the Registered Nurse (RN 1) at the patient's residence. Patient 10 was not at home. Several phone calls were made to Patient 10's three phone number listed on her clinical records, but calls have either no dial tone and/or went straight to voicemail. At 11:35 a.m., during an interview, RN 1 stated she does not know where Patient 1 was located. i. A review of Patient 11's admission record indicated the patient was admitted to the HA on 10/17/2021, with diagnosis of heart disease, unspecified (a type of disease that affects the heart or blood vessels). Patient 11's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated the registered nurse visit once every 2 weeks and as needed, and the licensed vocational nurse visit of once a week and one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of the "Physician's Certification for Hospice Benefit" signed by the Medical Director who was also the referring doctor, indicated Patient 11 has a life expectancy of six months or less, if the terminal illness runs its normal course. It also indicated Patient 11 meets LCD medical guidelines to receive hospice service. A review of the form "LCD Hospice Eligibility Determination" of Heart Disease dated 10/31/202, indicated section 1 - "Untreatable Condition", and section 2 - New York Heart Association (NYHA) Classification" must be met. It was mark "yes" in section 1 that Patient 11 has been ruled out as a candidate for surgical procedure. Section 2 was mark "yes" that Patient 11 met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). A review of Patient 11s clinical record indicated no documented evidence Patient 11 was ruled out as a candidate for surgical procedure related to heart disease. There was no documented evidence Patient 11 was on complete rest, confined to bed and chair, any physical activity brings on discomfort and symptoms occurs at rest. A review of Patient 11's "Comprehensive Nursing Assessment", dated 10/17/2021, indicated Patient 11 was alert and oriented x 4 (person, place, time, and event). Patient 11 was ambulatory with limping gait using a walker, and able to perform ADLs with minimal or moderate assistance. Patient 11's heart rate was irregular, at 93 beats per minute, oxygen saturation was 96% in room air and no edema was observed. Patient 11's NYHA documented classification was IV (New York Heart Association Class IV - patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." During a phone interview with Patient 11, on 9/12/2022 at 10:30 a.m., Patient 11 stated he was not aware of any surgical procedure about his heart, and he was doing okay. He stated he has mild symptoms when he went out for a walk but has no symptoms if he was in bed or chair. Patient 11 stated nobody told him that he has life expectancy of 6 months or less. j. A review of patient 12's admission record indicated the patient was admitted to the HA on 6/27/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Patient 12's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 12's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated skilled nurse (SN) visits once per week and one as needed. The hospice aide (HA), MSW, SC, and volunteer service were declined. A review of the "Physician's Certification for Hospice Benefit" from 6/27/2022 to 9/24/2022, signed by the Medical Director who was also the referring doctor, indicated "It is my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice". It also indicated Patient 12 meets LCD medical guideline criteria to receive hospice care/services. A review of the form of "LCD Hospice Eligibility Determination" of Pulmonary Disease dated 6/27/2022, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 12 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat less than or equal to 88% determined by O2 sat monitors. A review of Patient 12's clinical record indicated there was no documented evidence Patient 12 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators and had O2 saturation of 88% or less. A review of Patient 12's "Comprehensive Nursing Assessment", dated 6/27/2022, indicated Patient 12 was awake, alert, oriented (to person, place, time) and can answer appropriately to questions asked. Patient 12 was ambulatory using a cane or walker and noted with unsteady gait and able to perform ADLs with minimal or moderate assistance. Patient 12's oxygen saturation was 89% in room air. The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." On 9/08/2022, at 2:55 p.m., a home visit was conducted for Patient 12. Patient 12 was observed awake, alert, ambulatory, not on oxygen and not showing any signs and symptoms of pulmonary disease. Patient 12 stated he walks to the market everyday several blocks from where he lives and does not have shortness of breath. Patient 12 stated he was diagnosed with COPD since 2010, takes his medication/inhalers daily and is not going to die within 6 months. k. A review of Patient 13's admission record indicated the patient was admitted to the HA on 6/28/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 13's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated RN visits once every two weeks plus one visit as needed, and LVN visit once a week plus one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of the "Physician's Certification for Hospice Benefit" from 6/28/2022 to 9/25/2022, signed by the Medical Director who was also the referring doctor, indicated "It is my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice". It also indicated Patient 13 has increased episodes of shortness of breath mostly relieved with rest. A review of the form of "LCD Hospice Eligibility Determination (Local Coverage Determination-determining Terminal Status)" of Pulmonary Disease, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 13 had a disabling dyspnea at rest as evidenced by being poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat less than or equal to 88% determined by O2 sat monitors. A review of Patient 13's clinical record indicated there was no documented evidence Patient 13 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators and had O2 saturation of 88% or less. A review of Patient 13's "Comprehensive Nursing Assessment", dated 6/28/2022, indicated Patient 13 was awake, alert, oriented (to person, place, time), verbally responsive and can express needs and discomfort. Patient 13 was ambulatory with unsteady gait and noted with shortness of breath with moderate exertion that was relieved with rest and inhaler. Patient 13's oxygen saturation was 92% in room air. The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." On 9/9/2022 at 12:15 p.m., a telephone interview was conducted with the Medical Director of the agency. When asked whether he had his primary patient at the agency, he stated he had a lot of patients and he was not sure/recall. And then, he stated he was not a primary physician for all of the agency's patients. He stated he decides eligibility of hospice care based on signs/symptoms, diagnoses (including history and Physical, labs), ADLs, stability, bed bound status and frequency of hospitalization, and LCD assessment. He stated the Nurse Practitioner (NP) who had been working for him was supposed to review all the assessments including the History and Physical. He stated he had not actually reviewed the patients' History and Physical, and LCD Assessment. Instead, he relied on NP's judgement. When informed that there was no documentation supporting the LCD assessment and the patient's diagnoses, the medical director stated he did not know that. He stated NP 1, who had been working for him for 4-5 months, had been signed his signature electronically in the "Physician's Certification for Hospice Benefit" behalf of him. He stated he had another NP worked for him before NP 1, and he always had a NP worked for him. He stated he did not have any supportive documentation for the hospice eligibility assessment and had not communicated with the patients' attending physician. He stated he should have overseen things like eligibility of patients for the hospice service. During an interview with the Director of Patient Care Services (DPCS) on 9/12/2022 at 2:35 p.m., she stated she was not able to find the documented evidence Patient 10, 11, 12 and 13, were poorly responsive or unresponsive to bronchodilators resulting in decreased functional capacity, or had increased visits to Emergency Room, or had disabling dyspnea and oxygen saturation 88% and below, or patients been ruled out for a surgical procedure. A review of the agency's job description summary titled "Hospice Medical Director" revised April 2017 indicated the duties and responsibilities of the Medical Director will include, but not limited to, the following: * Reviewing patients' medical eligibility for hospice services, in accordance with the hospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness * Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. * Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. *Providing written certification of the terminal illness for all subsequent benefit periods.

h. A review of Patient 10's admission record indicated the patient was admitted to the HA on 1/07/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). Patient 10's admission information sheet (face sheet) indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 10's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated skilled nurse (SN) visits once per week and once per week as needed and change of condition for assessment and comfort monitoring, the spiritual counselor (SC) and medical social worker (MSW) to do assessment within 5 days from SOC (start of care), certification & as needed. The hospice aide (HA) and volunteer visit were declined. A review of Patient 10's Comprehensive Nursing Recertification Assessment, dated 7/05/2022, indicated Patient 10 was awake, alert, oriented (to time, place, person) and verbally responsive. Patient 10 was ambulatory using a cane with stand-by assist and able to perform ADLs (or activities of daily living, including bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) with minimal assistance. Patient 10 has normal respiration, no cough, no shortness of breath, and her vitals (blood pressure, temperature, pulse, respiratory rate) and oxygen saturation was not assessed. The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." A review of the "Physician's Certification for Hospice Benefit (the patient must be certified as being terminally ill to receive hospice care)" from 7/06/2022 to 9/03/2022, signed by the Medical Director who was also the referring doctor, indicated "I attest that I composed this narrative based on my review of patient's medical records, team assessment and/or examination of patient". It indicated Patient 10 was recertified for hospice and was appropriate for hospice admission with a terminal prognosis of 6 months or less if disease process follows its normal course. There has no documented evidence the hospice medical director communicated with the primary physician, to certify that Patient 10 had a life expectancy of 6 months or less, if the terminal illness runs it normal course. A review of the form "LCD Hospice Eligibility Determination" of Pulmonary Disease dated 7/05/2022, indicated section 1 and section 2 must be met. It was mark "yes" in section 1 that Patient 10 had a disabling dyspnea (shortness of breath) at rest as evidenced by being poorly responsive or unresponsive to bronchodilators (a type of medication that make breathing easier by relaxing the muscles in the lungs and widening the airways), resulting in decreased functional capacity. Section 2 was mark "yes" that Patient 10 had O2 sat (Oxygen saturation, the amount of oxygen you have circulating in your blood. Normal range will be around 95-100%) less than or equal to 88% determined by O2 sat monitors. A review of Patient 10's clinical record indicated there was no documented evidence Patient 10 had a disabling dyspnea at rest, was poorly responsive or unresponsive to bronchodilators and/or had O2 saturation of 88% or less. i. A review of Patient 11's admission record indicated the patient was admitted to the HA on 10/17/2021, with diagnosis of heart disease, unspecified (a type of disease that affects the heart or blood vessels). Patient 11's face sheet indicated the hospice Medical Director was also the patient's referring and attending physician. A review of Patient 11's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 6/20/2022, indicated the registered nurse visit once every 2 weeks and as needed, and the licensed vocational nurse visit of once a week and one visit as needed. The hospice aide, MSW, SC, and volunteer service were declined. A review of Patient 11's Comprehensive Nursing Recertification Assessment, dated 6/10/2022, indicated Patient 11 was awake, alert, and oriented (to person, place, and time). Patient 11 was ambulatory using a walker, and able to perform ADLs with minimal or moderate assistance. Patient 11 has no cardiac-related pain, no edema observed, no shortness of breath and has normal respirations. Patient 11's oxygen saturation was 97% on room air, and the rest of his vitals was not assessed. Patient 11's NYHA documented classification was IV (New York Heart Association Class IV - patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptom occurs at rest). The section for "Personal Care and Support Needs" indicated the need for hospice aide (HA), volunteer, and community support were marked as "None." A review of the "Physician's Certification for Hospice Benefit" signed by the Medical Director who was also the referring doctor, indicated Patient 11 has a life expectancy of six months or less, if the terminal illness runs its normal course. There has no documented evidence the hospice medical director communicated with the primary physician, to certify that Patient 11 had a life expectancy of 6 months or less, if the terminal illness runs it normal course. A review of the form "LCD Hospice Eligibility Determination" of Heart Disease, dated 2/02/2022, indicated section 1 - "Untreatable Condition", and section 2 - New York Heart Association (NYHA) Classification" must be met. It was mark "yes" in section 1 that Patient 11 has been ruled out as a candidate for surgical procedure. Section 2 was mark "yes" that Patient 11 met the criteria for NYHA Class IV level (New York Heart Association Class 4 - Patient who should be at complete rest, confined to bed or chair, any physical activity brings on discomfort and symptoms occurs at rest). A review of Patient 11s clinical record indicated no documented evidence Patient 11 was ruled out as a candidate for surgical procedure related to heart disease. There was no documented evidence Patient 11 was on complete rest, confined to bed and chair, any physical activity brings on discomfort and symptoms occurs at rest. During a phone interview with Patient 11, on 9/12/2022 at 10:30 a.m., Patient 11 stated he was not aware of any surgical procedure about his heart, and he was doing okay. He stated he has mild symptoms when he went out for a walk but has no symptoms if he was in bed or chair. Patient 11 stated nobody told him that he has life expectancy of 6 months or less. On 9/9/2022 at 12:15 p.m., a telephone interview was conducted with the Medical Director of the agency. When asked whether he had his primary patient at the agency, he stated he had a lot of patients and he was not sure/recall. And then, he stated he was not a primary physician for all of the agency's patients. He stated he decides eligibility of hospice care based on signs/symptoms, diagnoses (including history and Physical, labs), ADLs, stability, bed bound status and frequency of hospitalization, and LCD assessment. He stated the Nurse Practitioner (NP) who had been working for him was supposed to review all the assessment and documentation including the History and Physical. He stated he had not actually reviewed the patients' clinical documentation and LCD Assessment. instead, he relied on NP's judgement. When informed the Medical director that there was no documentation supporting the LCD assessment and the patient's diagnoses, he stated he did not know that. He stated NP 1, who had been working for him for 4-5 months, had been signed his signature electronically in the "Physician's Certification for Hospice Benefit" behalf of him. He stated he had another NP worked for him before NP 1, and he always had a NP work for him. He stated he did not have any supportive documentation for the hospice eligibility assessment, and had not communicated with the patients' attending physician. He stated he should have overseen things like eligibility of patients for the hospice service. A review of the agency's undated policy titled "Admission Criteria and Process" indicated the patient's life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediary's Local Coverage Determinations (LCDs). A review of the agency's undated Policy and Procedure titled "Certification of Terminal Illness" indicated the clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification. According to the LCD, the physician must briefly synthesize the clinical information supporting the terminal diagnosis, and attest that they composed the narrative after reviewing the clinical information and where applicable, examining the patient. A review of the agency's job description summary titled "Hospice Medical Director" revised April 2017 indicated the duties and responsibilities of the Medical Director will include, but not limited to, the following: * Reviewing patients'medical eligibility for hospice services, in accordance with the dhospice program policies and procedures, and establishing the plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness * Reviewing necessary data from the referral source in order to validate the diagnosis and life-limiting prognosis established by the attending physician. * Reviewing the clinical record and/or performing a medical examination to confirm the appropriateness of services. *Providing written certification of the terminal illness for all subsequent benefit periods.

b. A review of Patient 13's admission record indicated the patient was admitted to the HA on 6/28/2022, with diagnosis of chronic obstructive pulmonary disease, unspecified (COPD-a group of lung diseases that block airflow and make it difficult to breathe). A review of Patient 13's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 7/05/2022, indicated RN frequency of visits to once every two weeks plus one visit as needed, and LVN visit to once a week plus one visit as needed to assess and monitor effectiveness of medications, oxygen saturation, observe sign and symptoms of respiratory infection and identify shortness of breath (SOB) as effected by activity. A review of Patient 13's "Visit Note LVN", dated 7/18/2022, under the section "Respiratory", the item "Dyspnea (SOB)" indicated patient had light difficulty and on the comments below, it indicated "patient has shortness of breath and cough". But under the section "Narrative", it indicated "no shortness of breath noted". During a concurrent interview and record review with the Case Auditor (LVN 1), on 9/12/2022 at 2:15 p.m., LVN 1 acknowledged the finding and stated patient records should have accurate information. A review of the agency's policy and procedure titled "Entries into the Clinical Record", revised April 2017, indicated hospice personnel providing direct care and supervisory functions have authority to make entries into the clinical record. Documentation in the clinical record will be timely, detailed, accurate, and reflect the care or services provided.