Every finding on record at Divine Intervention Hospice, Inc

Based on interview and record review, the Hospice Agency (HA) failed to create an individualized plan of care for two of nine sample patients (Patient 15, Patient 21, and Patient 22). This failure had the potential to result in patients not receiving the appropriate services tailored for them during their end-of-life care which can cause pain and suffering. --- 1. A record review of Patient 16s face sheet indicated a start of care date on 6/21/2024, with a terminal diagnosis of heart disease. The record also indicated this was the patients second benefit period. During a concurrent interview and record review, on 9/25/2024, at 1:41 p.m., the director of nurses designee (DD) reviewed Patient 16s plan of care (POC), dated 9/12/2024. The DD stated the POC was not completed because it was missing the patients problems, interventions, goals, and frequency of services. The DD stated the potential outcome of not having a POC meant that if there was no POC, the HA did not have an order. An order was needed to provide care for the patient. The order should have been provided by the doctor and the interdisciplinary group (doctor, registered nurse, medical social worker, spiritual counselor). 2. During a record review of Patient 21s medical record form titled ";Patient Face Sheet" indicated a start of care date of 6/21/2024 with a primary diagnosis of atherosclerotic heart disease unspecified (inability of the heart to pump blood efficiently). During a record review of Patient 21s medical record form titled ";Certification of Plan of Care" dated 9/13/2024, indicated Registered Nurse 4 (RN4) and License Vocational Nurse 3s (LVN3) names were written on the form but neither staff member signed the form. During a concurrent interview and record review, on 9/23/2024 at 11:20 a.m. with the Director of Patient Care Services Designee (DD) of Patient 21s medical record form titled ";Certification of Terminal Illness" dated 9/19/2024, the DD stated it was not signed by the RN4 or Medical Director 1 (MD1). During a concurrent interview and record review, on 9/23/2024 at 11:20 a.m. with the DD of Patient 21s medical record form titled ";Physician Order Details" dated 9/13/2024, the DD stated the form was not signed by either MD1 or RN4. The DD stated MD1 was supposed to sign the form on 9/19/2024. The DD stated the author of the order is unknown because it was not signed. On 9/25/2024 at 11:53 a.m. Patient 21 was called; the call was not answered. Message with call back number left. On 9/26/2024 at 8:16 a.m. Patient 21 was called; the call was not answered. Message with call back number left. 3. During a record review of Patient 22s medical record form titled ";Patient Face Sheet" indicated a start of care date of 6/26/2024 with a primary diagnosis of atherosclerotic heart disease unspecified (inability of the heart to pump blood efficiently). During a concurrent interview and record review, on 9/25/2024 at 2.pm. with the DD of Patient 22s EMR, DD stated Patient 22s individualized plan of care was not completed for her second recertification period, which was from 9/24/2024 to 12/22/2024. The DD stated Patient 22s care plan was missing her issues, the nurses interventions, and the patients goals. DD stated the skilled nurses and other disciplines follow the plan of care and that is why it was important that each patient had a plan of care. During an interview on 9/25/2024 at 2:29 p.m. with Patient 22, Patient 22 stated that the HA nurse visits every Wednesday. Patient 22 stated the visiting nurse checks her pulse, blood pressure and oxygenation. Patient 22 stated the visiting nurse does not check her medications.

Based on observation, interview and record review, the hospice agency failed to meet the Conditions of Participations regarding Initial and Comprehensive Assessments of Patients as follows: --- 1. The Hospice Agency failed to ensure an accurate 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) that reflected the patients current health status and patients' need for hospice care (a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life and prioritizes comfort and quality of life by reducing pain and suffering) and services related to hospice eligibility and management of terminal illness (a patient with a life expectancy of six months or less to live) was conducted for five of fourteen sampled patients (Patients 2, 3, 8, 9, and 10). (Refer to L 522) 2. The Hospice Agency failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) met, discussed and completed the comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) no later than five calendar days after hospice election, for ten of fourteen sampled patients (Patients 1, 2, 3, 4, 8, 9, 10, 11, 12, and 13). (Refer to L 523). 3. The Hospice Agency failed to conduct or attempt to conduct a bereavement assessment (assessing participants and grieving families to ensure that appropriate bereavement services are provided through the continuum of care from enrollment through the year following the death of the participant) to provide bereavement counseling in accordance with the patient/family's needs, for eleven of fourteen sampled patients (Patients 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, and 12). (Refer to L 531). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated Federal compliance with Federal regulations for Initial and Comprehensive Assessment of Patients to ensure highest quality of care are provided to patients certified to receive hospice care services.

Based on interview and record review, the Hospice Agency failed to ensure an accurate 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) that reflected the patients current health status and need for hospice care (a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life and prioritizes comfort and quality of life by reducing pain and suffering) and services, related to hospice eligibility and management of terminal illness (a patient with a life expectancy of six months or less to live), was conducted for five of fourteen sampled patients (Patients 2, 3, 8, 9, and 10). This deficient practice resulted in the hospice agency claiming reimbursement for patients who may not require hospice care and services and had the potential for the patients to not receive the appropriate healthcare services needed to maintain quality life. --- 1. A review of Patient 2's ";Patient Face Sheet", indicated a start of care date (SOC) on 7/20/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During an interview on 10/12/2023, at 10 a.m., Patient 2 stated he did not have a terminal illness (a patient with a life expectancy of six months or less to live), a doctor had not told him that he had 6 months or less to live, and that he was not going to die anytime soon. Patient 2 stated his mind was fine, and he was taking care of his mother. Patient 2 stated he goes out of the house to make sure his mother was okay. Patient 2 stated hospice care (a type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life and prioritizes comfort and quality of life by reducing pain and suffering) was for people who would be passing away, and ";I know you dont have to be dying to be in hospice care. Eventually we all die. This program basically takes care of me until I reach that point." During an interview on 10/13/2023, at 2:10 p.m., the Director of Nursing Designee (DD) stated Patient 2 was qualified for hospice care due to his heart disease and symptoms. DD stated the information used to complete the 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) was the patient report and nursing assessment. DD stated there was no history and physical (H&P- physicians documentation describing medical problems, interventions, and plan) or any other documents to support Patient 2's diagnosis. During a record review of Patient 2's document titled, ";Local Coverage Determination (LCD, provides guidance in determining medical necessity of services) Guidelines for Determining Prognosis due to heart disease", dated 7/20/23, indicated Patient 2 had progression of disease as documented by worsening clinical status, symptoms, signs and laboratory results. Further review of the record indicated Patient 2 was dependent on assistance for ambulation and transfer. Patient 2s heart functional classification indicated he was comfortable only at rest. During a record review of Patient 2s document titled, ";Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less)", dated 7/20/23, did not indicate a signature of the doctor, to indicate Patient 2 was certified for hospice care. Patient 2's initial assessment did not indicate documented evidence to identify Patient 2's qualifications for hospice care. 2. During a review of Patient 3's ";Patient Face Sheet", indicated a start of care date (SOC) on 9/18/23, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During an interview on 10/12/23, at 9:36 a.m., Patient 3 stated he signed up to hospice services because the agency would provide him with medical supplies, protein drinks, and a care giver. Patient 3 stated he had a primary care doctor through the veteran's (a person who has served in the military) administration clinic. Patient 3 stated he did not have a terminal illness and no doctor had told him he had 6 months or less to live. Patient 3 stated he goes for walks using a walker and did not feel short of breath when walking. Patient 3 stated he did not use or need oxygen when walking. During an interview on 10/13/2023, at 2:20 p.m., DD stated Patient 3 was qualified for hospice care due to his heart disease, uncontrolled blood pressure, and cholesterol problems. DD stated the information used to complete the initial comprehensive assessment was the patient report and nursing assessment. DD stated there was no H&P or any other documents to support Patient 3s diagnosis. A record review of Patient 3s document titled, ";LCD Guidelines for Determining Prognosis due to heart disease", dated 9/18/23, indicated Patient 3 had progression of disease as documented by worsening clinical status, symptoms, signs, and laboratory results. Further review of the record indicated Patient 3s symptoms were short of breath (dyspnea) with increasing respiratory rate. Patient 3s heart functional classification indicated he had cardiac disease with marked limitation due to symptoms, even during less than ordinary activity such as walking short distances, being comfortable only at rest. A record review of Patient 3s document titled, ";Certification of Terminal Illness", dated 9/18/23, did not indicate a signature of the doctor, to indicate Patient 3 was certified for hospice care. Patient 3s initial assessment did not indicate documented evidence to identify Patient 3's qualifications for hospice care. 3. During a review of Patient 8s clinical record titled, ";Patient Face Sheet" indicated a Start of Care (SOC) date of 12/6/2022 with diagnoses including hypertensive heart disease without heart failure (heart changes due to long term uncontrolled high blood pressure). During a joint home visit on 10/12/2023 at 12:10 p.m., with the DD to Patient 8s home, DD stated Patient 8 was awake, oriented, ambulatory, and that Patient 8 manages his own meds. Patient 8 was noted sitting on dining room chair, fully clothed with shoes on. Patient 8 stated that hospice was a program for patients that have ";certain conditions" that may cause death. Patient 8 also stated that they provided medications, wipes, and lotions. Patient 8 stated that he saw his primary doctor about one and a half weeks ago at his Clinic stated that he was not told that he had six months or less to live by any doctor. During a review of Patient 8s clinical record titled, ";Initial Assessment" dated 12/6/2022, indicated Patient 8 had a functional limitation on ambulation, required assistance with ambulation and transfer, unable to do light housekeeping and personal laundry. It also indicated, ";Coordination of Care – Collaboration with: MSW (Medical Social Worker), Medical Director, and attending physician. The assessment form indicated it was signed by RN2. During a review of Patient 8s clinical record titled, ";Certification of Terminal Illness (CTI)" dated 12/6/2022, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI indicated the MD1s name, however, the certification form was not signed by MD1. During a review of Patient 8s clinical record titled ";Nursing Clinical Note", signed by RN3, dated 9/28/2023, indicated ";Imminence of death: no signs of imminent death at this time. Pain assessment no reportable or observable pain at this time. Mental status oriented to name/person, time, place, situation/current events. Neurological no significant findings. Responsiveness no significant findings. Skin dry, intact, warm no significant findings. Sleep no significant findings, respiratory no significant findings, cardiovascular heart sound regular, edema none, pulses strong, gastrointestinal no significant findings. Nutrition/hydration appetite good consumed 70 – 80% of served. Endocrine- no significant findings. Genitourinary/reproductive no significant findings". During a review of Patient 8's clinical record titled, ";Certification of Terminal Illness" dated 9/29/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI indicated the Medical Directors 1 (MD1) name, however, the certification form was not signed by MD1. Patient 8's assessment did not indicate documented evidence to identify Patient 8's qualifications for hospice care. 4. During a review of Patient 9s clinical record titled, ";Patient Face Sheet" indicated a Start of Care (SOC) date of 6/30/2023, with diagnoses including atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow to the heart due to plaque buildup). During a review of Patient 9s clinical record titled ";Initial Assessment", dated 6/30/2023, indicated Patient 9 had functional limitations: such as ambulation. It also indicated under section ";Pain Assessment: Non-Verbal: Moans" and indicated Patient 9 required assistance with ambulation, transferring, toileting, bathing, meal preparation, grocery shopping, light housekeeping, medication administration, personal laundry, and using phone. It also indicated, ";Coordination of Care – Collaboration with: MSW, Medical Director, and attending physician. The initial assessment form indicated it was signed by DD. During a review of Patient 9s clinical record titled ";Certification of Terminal Illness" dated 6/30/2023, indicated ";I confirm that this narrative was composed by me and was based on my review of the patients medical record and/or examination of the patient." The CTI indicated the MD1s name, however, the certification form was not signed by MD1. During a joint home visit on 10/12/2023, at 10:30 a.m., with the DD to Patient 9s home, DD stated Patient 9 lives alone, manages her own medication, is continent, awake and alert. Patient 9 ambulated well, was fully dressed, and was holding her cell phone. Patient 9 stated that she goes to the nail salon to do her nails frequently, and was last in the salon a month ago. Patient 9 stated that she walks to church every Sunday. Patient 9 stated that she left her medications and hospice binder at her sons house where she spent the night last night. Patient 9 stated that she has a primary doctor that she has been with for the past 5 years. Patient 9 stated that she has an appointment soon with her Primary Doctor (PCP1). Patient 9 stated that there has not been a doctor who told her that she has 6 months or less to live. Patient 9 stated that she wouldnt know what do if she heard that she would die in 6 months. During a telephone interview on 10/12/2023, at 11:30 a.m., with Patient 9s PCP1s Nurse (NM), NM stated that PCP1 has not referred Patient 9 for hospice care. NM stated that PCP1 was going to call Patient 9 to find out what was going on. During a review of Patient 9s clinical record titled, ";Nursing Clinical Note" dated 9/30/2023, indicated ";Imminence of death – no signs of imminent death at this time. Mental status – oriented to name/person, time, place, situation/current events. neurological – unsteady gait. responsiveness – no significant findings. Skin – intact, warm. sleep – no significant findings. Respiratory – no significant findings. cardiovascular – heart sound regular, edema none, pulses no significant findings. gastrointestinal – no significant findings. Nutrition/hydration – appetite good. Musculo-skeletal impaired mobility, limited range of motion, unsteady gait." The Nursing Clinical Note indicated it was signed by RN1. During a review of Patient 9s clinical record titled, ";Certification of Terminal Illness", dated 8/25/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI indicated the MD1s name, however, the certification form was not signed by MD1. 5. During a review of Patient 10s clinical record titled, ";Patient Face Sheet" indicated a Start of Care (SOC) date of 9/21/2023 with diagnoses heart disease unspecified (inability of the heart to pump blood adequately). During a telephone interview on 10/13/2023 at 8:25 a.m., Patient 10 stated, the HA provides shampoo, blood pressure machine and a glucometer (machine to check blood sugar). Patient 10 stated she had a primary doctor (PCP2) and has been seeing him for five years. Patient 10 stated that she will see PCP2 on 10/23/2023 for blood draw and then again on 10/31/2023 to get the results. Patient 10 stated that she picks up her granddaughter from school daily, goes to the market and sometimes to get fast food. Patient 10 stated that she walks a lot, that sometimes to the beach. Patient 10 stated that there has never been a doctor who has told her she had six months or less to live. During a telephone interview on 10/13/2023, at 8:34 a.m., with Patient 10s Primary Doctors Nurse (BM), BM stated that PCP2 was on leave. BM stated that PCP2 had been seeing and treating Patient 10 for the past five years. BM stated that Patient 10s next appointment was on 10/23/2023 for a blood draw, then on 10/31/223 to see PCP2. BM stated that Patient 10 had been referred for physical therapy, but not for hospice care. BM stated ";I dont see a hospice referral. She hasnt even been admitted to a hospital. Usually hospice patients are bed-bound she is not. There are no hospice referrals." During a review of Patient 10s clinical record titled, ";Initial Assessment" dated 9/21/2023, indicated functional limitations: ambulation and dyspnea with minimal exertion. Form indicated Patient 10 lives alone. It also indicated, ";Coordination of Care – Collaboration with: MSW, Medical Director, and attending physician. Under ";Summary/Plan/Support Diagnosis: Patient lives alone at senior apartment buildings... emphasized on pt (patient) and PCG (patient care giver) the importance of perineal care after each change of adult brief to reduce risk of infection and instructed n ot to let pt sit on soiled briefs for a long time to percent skin irritation". The initial assessment form indicated it was signed by RN3. During a review of Patient 10s clinical record titled, ";Certification of Terminal Illness", dated 9/21/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI indicated the MD1s name, however, the certification form was not signed by MD1. During a review of Patient 10s clinical record titled, ";Nursing Clinical Note" dated 9/29/2023, indicated ";Imminence of death – no signs of imminent death at this time. mental status – oriented to name/person, time, place, situation/current events. respiratory – dyspnea with exertion. Under ";Summary/Plan/Support Diagnosis: SOB (shortness of breath) on moderate exertion relieved with rest. Emphasized on pt (patient) and PCG (patient care giver) the importance of perineal care after each change of adult brief to reduce risk of infection and instructed not to let pt sit on soiled briefs for a long time to percent skin irritation". The Nursing Clinical Note indicated it was signed by License Vocational Nurse 1 (LVN1). During a review of the HAs policy and procedure (P&P) titled, ";Initial Assessment/Comprehensive Assessment", dated June 2019, indicated, ";Each patient admitted to Hospice will have an appropriate initial assessment and comprehensive assessment performed and documented which promote the patients well-being, comfort and dignity throughout the dying process." During a record review of the HAs P&P titled, ";Initial Assessment/Comprehensive Assessment", dated June 2019, indicated, ";Procedure...2.Each patient admitted will receive a comprehensive assessment. The comprehensive assessment will identify the patients need for Hospice care and identify the patients need for: ...Psychosocial and emotional care. Spiritual care".

Based on interview and record review, the Hospice Agency failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) met, discussed and completed the comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed in order to promote the hospice patient's well-being, comfort, and dignity throughout the dying process) no later than five calendar days after hospice election for ten of fourteen sampled patients (Patients 1, 2, 3, 4, 8, 9, 10, 11, 12, and 13). This failure had the potential for patients to not receive the appropriate healthcare and services necessary to maintain quality care and quality of life. --- During an interview on 10/11/2023, at 2 p.m., with Director of Nurses Designee (DD), the DD stated that Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings had been held every two weeks via zoom (online). The DD stated that the IDT members included a Registered Nurse (RN), Spiritual Counsellor (SC), Medical Social Worker (MSW), and the Medical Director (MD) and that all had access to the patients electronic medical record (EMR) system. The DD stated that all attendees of the IDT meetings had to sign and date when attending the meeting, which will indicate as an ";e-sign". The DD stated that the attendees signatures indicated they had understood, agreed, and validated patients specific plan of care. The DD stated that the last IDT meeting was held last 9/19/2023. During an interview on 10/13/2023, at 1:07 p.m., with the Director of Nurses (DON), the DON stated that the IDT meetings are held the same day of the patients admission with the core members, which included RN, MSW, MD and Chaplain. The DON stated that all members need to participate in the IDT meetings to be able to meet the patients' needs. The DON also stated that DD was responsible to attend the IDT meetings. The DON stated that ";IDT meetings are important in order for the core team to know what is going on with the patient. If the IDT meetings are not being done every 14 days, then we could not meet the needs of the patient. If the patient needs are not met, the patient can be neglected." The DON stated that members signs the IDT meetings via their EMR the same day the meeting are held. During a telephone interview on 10/13/2023, at 1:07 p.m., with the SC, the SC stated he participated in the IDT meetings via zoom. The SC stated that they discuss the patients conditions to see if there are any change in condition and stated that he had access to the HAs EMR where he documents his discussion and signs the IDT meeting. The SC stated that his signature validates his input. The SC stated that the HAs last IDT meeting was held a week ago, and that the meetings are held every Tuesday. During a telephone interview on 10/13/2023, at 1:21 p.m., with the MSW, the MSW stated that she visits the patients within 5 days of admission. The MSW stated that patients are discussed in the IDT meetings and stated that she enters her input and electronically signs within two days of the meeting in the HAs EMR. The MSW stated that she was on vacation for the past two weeks and that the last time she attended an IDT meeting was sometime in the middle of September. 1. A review of Patient 1 ";Patient Face Sheet", indicated a start of care date (SOC) on 12/13/22, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During an interview on 10/13/2023, at 12:03 p.m., the DD stated the nurse doing the initial comprehensive assessment identifies the problems and discusses it with members of the IDG group including the MSW, SC and MD on admission. The DD stated the IDG group discuss the interventions needed for the patient, and a plan of care is formulated. During an interview on 10/13/2023, at 12:07 p.m., the DD reviewed Patient 1s document titled, ";Initial Orders and Plan of Care", dated 12/13/22 and stated the SC was the only one that signed the record. The DD stated the record had missing signatures from the RN, MSW, and MD. The DD stated the signatures are important because it validated their participation and agreement to the plan of care. The clinical record did not indicate documented evidence that the IDG members were involved in the completion of the comprehensive assessment no later than 5 calendar days. 2. During a review of Patient 2s ";Patient Face Sheet", indicated a start of care date (SOC) on 7/20/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During an interview on 10/12/2023, at 10:00 a.m., Patient 2 stated the HA had not offered a SC. During a record review of Patient 2s document titled, ";Initial Orders and Plan of Care", dated 7/20/23, the document did not indicate signatures of the MD, RN, MSW, and SC in the completion of the comprehensive assessment. Further review of the record indicated Patient 2 had declined a spiritual care visit. 3. During a review of Patient 3's ";Patient Face Sheet", indicated a start of care date (SOC) on 9/18/23, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/2023, at 11:40 a.m. with the DD, Patient 3s record titled ";Divine Intervention Hospice Inc.", dated 9/18/23, the DD stated the psychosocial assessment was not done and should have been done within 5 days of the start of care. The DD stated the potential outcome of this deficient practice was a delay in identifying the needs of Patient 3. The DD stated Patient 3 did not have a plan of care developed based on the psychosocial needs of the patient. 4. During a review of Patient 4s ";Patient Face Sheet", the face sheet indicated a start of care date (SOC) on 4/22/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/2023, at 11:45 a.m., with the DD, Patient 4 s record titled ";Divine Intervention Hospice Inc.", dated 4/22/23. The DD stated the psychosocial assessment was not done and should have been done within 5 days of the start of care. The DD stated the potential outcome of this deficient practice was a delay in identifying the needs of Patient 4. The DD stated Patient 4 did not have a plan of care developed based on the psychosocial needs of the patient. 5. During a review of Patient 8s medical record form titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 12/6/2022 with diagnoses including hypertensive heart disease without heart failure (heart changes due to long term uncontrolled high blood pressure). During a review of Patient 8's clinical record titled, ";Initial Assessment" dated 12/6/2022, indicated ";Coordination of Care – Collaboration with: MSW (Medical Social Worker), Medical Director, and attending physician. The form indicated it was signed by RN2. During a concurrent interview and record review on 10/11/2023 at 2:07 p.m. of Patient 8s EMR with the DD, the DD stated Patient 8s initial IDT meeting was held on 12/13/2023 which was within two weeks of a patients admission. The DD stated Patient 8s initial IDT meeting was not signed by any IDT members. 6. During a review of Patient 8s medical record form titled ";IDT Plan of Care & Review of Comprehensive Assessment" dated 12/13/2022, indicated ";The following IDT members updated / reviewed the interdisciplinary Team Plan of Care", however, the form did not indicate any signatures. 7. During a review of Patient 9s clinical record titled, ";Patient Face Sheet" indicated a Start of Care (SOC) date of 6/30/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow to the heart due to plaque buildup). During a concurrent interview and record review of Patient 9s EMR on 10/13/2023 at 11:27 a.m., with License Vocational Nurse 2 (LVN2), LVN2 stated Patient 9s initial IDT meeting was held on 7/11/2023. LVN2 stated that Patient 9s initial IDT meeting did not have e-signatures that would indicate the IDT teams attendance. During a review of Patient 9s clinical record titled, ";Initial Assessment" dated 6/30/2023, indicated, ";Coordination of Care – Collaboration with: MSW, Medical Director, and attending physician and was signed by DD. During a review of Patient 9s clinical record titled ";IDT Plan of Care & Review of Comprehensive Assessment", dated 7/11/2023, ";The following IDT members updated / reviewed the interdisciplinary Team Plan of Care", however it did not indicate any IDT teams signature. 8. During a review of Patient 10s clinical record titled, ";Patient Face Sheet" indicated a Start of Care (SOC) date of 9/21/2023 with diagnoses heart disease unspecified (inability of the heart to pump blood adequately). During a concurrent interview and record review on 10/11/2023 at 2:48 p.m. with DD of Patient 10s EMR, the DD stated the patient's initial IDT meeting was held on 10/3/2023. DD stated that Patient 10s initial IDT meeting was not signed by any IDT members. During a review of Patient 10s clinical record titled, ";Initial Assessment" dated 9/21/2023, indicated ";Coordination of Care – Collaboration with: MSW, Medical Director, and attending physician, and the form was signed by RN3. During a review of Patient 10s clinical record titled. ";IDT Plan of Care & Review of Comprehensive Assessment" dated 9/21/2023, indicated ";The following IDT members updated / reviewed the interdisciplinary Team Plan of Care", however the form did not indicate the IDT teams signature. 9. During a review of Patient 11s clinical record titled, ";Patient Face Sheet" indicated a Start of Care (SOC) date of 5/3/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow to the heart due to plaque buildup). During a concurrent interview and record review on 10/13/2023 at 2:30 p.m. with LVN2, LVN2 stated the patient's initial IDT meeting was held on 5/16/2023. LVN2 stated that Patient 11s initial IDT meeting did not have e-signatures. LVN2 stated that if the document was not signed it means it was not done. During a review of Patient 11s clinical record titled ";Initial Assessment" dated 9/28/2023, indicated, ";Coordination of Care – Collaboration with: Medical Director, and attending physician and was signed by DD. 10. During a review of Patient 12s clinical record titled ";Patient Face Sheet", indicated a Start of Care (SOC) date of 12/6/2022 with diagnoses including unspecified psychosis not due to a substance or known physiological condition (loss of touch with reality and may involve hallucinations, delusions, disordered thinking, and behavioral changes). During a concurrent interview and record review on 10/13/2023 at 3;20 p.m. with LVN2, LVN2 stated Patient 12s initial IDT meeting was held on 12/13/2023. LVN2 stated that Patient 12s initial IDT meeting did not have any e-signatures. LVN2 stated that if the document was not signed it means it was not done. During a review of Patient 12s clinical record titled ";Initial Assessment" dated 12/6/2023, indicated, ";Coordination of Care – Collaboration with: MSW, Medical Director, and attending physician. Form also indicated it was signed by RN2. During a review of Patient 12s medical record form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 12/13/2023, ";The following IDT members updated / reviewed the interdisciplinary Team Plan of Care", however, the IDT form did not indicate any of the IDT teams signature. 11. During a review of Patient 13s clinical record titled ";Patient Face Sheet", indicated a Start of Care (SOC) date of 2/20/2023 and an End of Care (EOC) date of 6/30/2023, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one‐sided weakness, but without complete paralysis). During a concurrent interview and record review on 10/13/2023 at 4 p.m. with LVN2 of Patient 13s EMR, LVN2 stated the patient's initial IDT meeting was held on 2/21/2023. LVN2 stated that Patient 13s initial IDT meeting had no signatures. LVN2 stated that if the document was not signed, it was not done. During a review of Patient 13s clinical record titled ";Initial Assessment" dated 2/20/2023, indicated, ";Coordination of Care – Collaboration with: MSW, Medical Director, and attending physician and was signed by DD. During a review of Patient 13's clinical record titled ";IDT Plan of Care & Review of Comprehensive Assessment", dated 2/21/2023, ";The following IDT members updated / reviewed the interdisciplinary Team Plan of Care", however, the IDT form did not indicate any of the IDT teams signature. During a review of the HAs policy and procedure titled, ";Initial Assessment/Comprehensive Assessment", dated June 2019, indicated, ";Procedure...4. The Hospice IDG, in consultation with the patients attending physician (if any), must complete the comprehensive assessment no later than 5 calendar days after patients election of Hospice care.

Based on interview and record review the Hospice Agency (HA) failed to conduct or attempt to conduct a bereavement assessment (assessing participants and grieving families to ensure that appropriate bereavement services are provided through the continuum of care from enrollment through the year following the death of the participant) to provide bereavement counseling in accordance with the patient/family's needs for eleven of fourteen sample selected patients (Patients 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, and 12). This deficient practice had the potential for the patient and family not being provided the social, spiritual, and cultural support related to the patient's death. --- During an interview on 10/13/2023, at 1:07 p.m., with the Director of Nurses (DON), DON stated that the Chaplain (SC) is responsible for patients initial bereavement assessment (assessing participants and grieving families to ensure that appropriate bereavement services are provided through the continuum of care from enrollment through the year following the death of the participant) upon admission. The DON stated that if a patient initially refused SC services, it is discussed in the hospice agencys interdisciplinary team (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting. The DON stated that the SC needs to contact the patients within 14 days of admission, even though patient refuses their services. During a telephone interview on 10/13/2023, at 1:07 p.m., with the SC, SC stated he is the bereavement coordinator, and he assesses patients within five days of their admission. SC stated that even though a patient declines, he remains available to them. SC stated, ";If they already refused it, I dont reach out unless a nurse asks me to reach out or until the next recertification." 1. During a review of Patient 1 ";Patient Face Sheet", indicated a start of care date (SOC) on 12/13/22, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During an interview on 10/13/23 at 10:04 a.m., the Director of Nursing (DON) stated the bereavement assessments are being done and documented in the 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) on admission. The DON stated the Registered Nurse (RN) was responsible in doing the bereavement assessment. The DON stated the bereavement assessment in the initial comprehensive assessment was not as detailed. A detailed bereavement assessment involved the caregiver, and asks more detailed questions about the bereavement, mortuary, and bereavement plans. During a concurrent interview and record review on 10/13/2023, at 10:10 a.m. with the DD, Patient 1s clinical record titled, ";Divine Intervention Hospice Inc.", dated 12/13/22 did not indicate a bereavement assessment was done for Patient 1. 2. During a review of Patient 2s ";Patient Face Sheet", indicated a start of care date (SOC) on 7/20/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/2023, at 10:15 a.m. with the DD, Patient 2s clinical record titled, ";Divine Intervention Hospice Inc.", dated 7/20/23 did not indicate a bereavement assessment was done for Patient 2. The DD stated it was important to have a bereavement assessment because every assessment is the start on how to approach the plan of care. The RN was supposed to be the one doing the assessment. The DD stated the potential outcome is a delay in the process of the plan of care pertaining to the bereavement. 3. During a review of Patient 3s ";Patient Face Sheet", indicated a start of care date (SOC) on 9/18/23, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/2023, at 10:16 a.m. with the DD, Patient 3s record titled, ";Divine Intervention Hospice Inc.", dated 9/18/23, indicated, ";Evaluation of Bereavement Risk: Moderate-moderate impairment to daily function". The DD stated moderate meant Patient 3 was able to cope with the bereavement, and the Spiritual Counselor did not need to go right away. The DD stated a detailed assessment was missing. DD stated it was important to have more information about bereavement such as how the patient was coping, description, and the family care giver response to bereavement, to develop the plan of care. DD stated she did not think Patient 3 needed a bereavement care plan because he was able to cope with the bereavement process. 4. During a review of Patient 4's ";Patient Face Sheet", indicated a start of care date (SOC) on 4/22/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/2023, at 10:31 a.m. with the DD, Patient 4s record titled, ";Divine Intervention Hospice Inc.", dated 4/22/23, indicated, ";Evaluation of Bereavement Risk: Moderate-moderate impairment to daily function". The DD stated the bereavement assessment that was done was not detailed and the comprehensive assessment did not show what the patient's bereavement needs were. 5. During a review of Patient 5's ";Patient Face Sheet", indicated a start of care date (SOC) on 9/27/23 with a diagnosis of hypertensive heart disease without heart failure (high blood pressure). During a concurrent interview and record review on 10/13/2023, at 10:42 a.m., the DD reviewed Patient 5s record titled, ";Divine Intervention Hospice", dated 9/27/23 that indicated the initial comprehensive assessment. The DD stated the record indicated, ";Evaluation of Bereavement Risk: Moderate-moderate impairment to daily function", however, the DD stated the bereavement assessment was not detailed and Patient 5's bereavement needs were not identified. The DD stated a ";moderate" assessment finding meant needs are identified, description of those needs and development of a plan of care related to those needs. 6. During a review of Patient 6's ";Patient Face Sheet", indicated a start of care date (SOC) on 6/27/23 with a diagnosis of malignant neoplasm of bladder (cancer in the bladder). During a concurrent interview and record review on 10/13/2023, at 10:51 a.m., the DD reviewed Patient 6's record titled, ";Divine Intervention Hospice Inc.", dated 6/27/23. The DD stated Patient 6 was imminently dying when he was admitted. The DD stated there was no initial bereavement assessment and care plan because the nurses forgot to document it. DD stated the bereavement needs of Patient 6 were not identified. DD stated Patient 6 passed away on 6/29/23. 7. During a review of Patient 8s clinical record titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 12/6/2022 with diagnoses including hypertensive heart disease without heart failure (heart changes due to long term uncontrolled high blood pressure). During a concurrent interview and record review on 10/13/2023 at 12:20 p.m. with License Vocational Nurse 2 (LVN2) of Patient 8s Electronic Medical Record (EMR), LVN2 stated that MSW documented a visit but did not document an initial bereavement assessment, which should have been completed within five days of admission. LVN2 stated that an initial bereavement assessment is needed to know who will be the bereaved. 8. During a review of Patient 9s clinical record titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 6/30/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow to the heart due to plaque buildup). During a concurrent interview and record review on 10/13/2023 at 11:27 a.m. with LVN2 of Patient 9s EMR, LVN2 was unable to find a documented initial bereavement assessment for Patient 9. LVN2 stated that Patient 9 refused SC and MSW visits. LVN2 stated that the MSW needs to reach out despite the patient's refusal to explain their services. 9. During a review of Patient 10s clinical record titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 9/21/2023 with diagnoses heart disease unspecified (inability of the heart to pump blood adequately). During a concurrent interview and record review on 10/13/2023 at 1:50 p.m. with LVN2 of Patient 10s EMR, LVN2 stated that there was no initial bereavement assessment documented. LVN2 stated that the initial bereavement assessment was needed to ";know who the bereaved will be..." 10. During a review of Patient 11s clinical record titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 5/3/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow to the heart due to plaque buildup). During a concurrent interview and record review on 10/13/2023 at 1:50 p.m. with LVN2 of Patient 11s EMR, LVN2 stated that there was no initial bereavement assessment documented. LVN2 stated that the initial bereavement assessment was needed to ";know who the bereaved will be..." 11. During a review of Patient 12s clinical record titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 12/6/2022 with diagnoses including unspecified psychosis not due to a substance or known physiological condition (loss of touch with reality and may involve hallucinations, delusions, disordered thinking, and behavioral changes). During a concurrent interview and record review on 10/13/2023 at 3:20 p.m. with LVN2 of Patient 12s EMR, LVN2 stated that there was no initial bereavement assessment documented. LVN2 stated that the initial bereavement assessment was needed to identify the bereaved. A record review of the HAs policy and procedure titled, ";Initial Assessment/Comprehensive Assessment", dated June 2019, indicated, ";Procedure...3...An initial bereavement risk assessment of the needs of the patients family and other individuals focusing on the social, spiritual, and cultural factors that may impact their ability to cope wit the patients death. Information gathered from the initial bereavement assessment must be incorporated into the plan of care and considered in the bereavement plan of care..." A record review of the HAs undated policy and procedure titled, ";Bereavement Services", indicated, ";Procedure 1. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice..."

Based on interview and record review, the Hospice Agency failed to meet the Condition of Participation for Interdisciplinary group, care planning, and coordination of services as follows: --- 1. The hospice agency failed to ensure the Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) met to discuss and formulate an individualized plan of care (POC, the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers), for five of fourteen sampled patients (Patients 1, 2, 5, 6, and 9). (Refer to L543). 2. The hospice agency failed to ensure the IDG members conducted a meeting to review and revise individualized patients plan of care at least every 15 days, for the thirteen of fourteen sampled patients (Patients 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, and 14). (Refer to L552). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated Federal compliance with Federal regulations for Interdisciplinary group, care planning, and coordination of services to ensure highest quality of care are provided to patients certified to receive hospice care services.

Based on interview, and record review, the hospice agency failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) met to discuss and formulate an individualized plan of care (POC the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) for five of fourteen sample selected patients (Patients 1, 2, 5, 6, and 9). This deficient practice had the potential to result to a poor-quality care when patient needs were not properly assessed and identified. --- 1. A review of Patient 1's ";Patient Face Sheet", indicated a start of care date (SOC) on 12/13/22, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During an interview on 10/13/23, at 12:03 p.m., the Director of Nursing Designee (DD) stated the nurse doing the 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) identifies problems and discusses it with members of 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) including the medical social worker (MSW), Spiritual Counselor (SC) and Medical Doctor (MD) on admission. The DD stated the IDG group discuss the interventions needed for the patient, and a plan of care is formulated. During an interview on 10/13/2023, at 12:07 p.m., the DD reviewed Patient 1s document tiled, ";Initial Orders and Plan of Care", dated 12/13/22. DD stated the SC was the only one that signed the record. DD stated the record had missing signatures from the Registered Nurse (RN), MSW, and MD. The DD stated the signature was important because it validated their participation and agreement to the plan of care. The hospice agency failed to ensure all IDG members were involved in the development of the plan of care for Patient 1. 2. During a review of Patient 2's ";Patient Face Sheet", indicated a start of care date (SOC) on 7/20/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a record review of Patient 2s document titled, ";Initial Orders and Plan of Care", dated 7/20/23, did not indicate the RN, MD, MSW, and SC were involved in the development of the plan of care. There were no signatures on the document. The hospice agency failed to ensure all IDG members were involved in the development of the plan of care for Patient 1. 3. During a review of Patient 5's ";Patient Face Sheet", indicated a start of care date (SOC) on 9/27/23 with a diagnosis of hypertensive heart disease without heart failure (high blood pressure). During a record review of Patient 5s document titled, ";Initial Orders and Plan of Care", dated 9/27/23, did not indicate the RN, MD, MSW, and SC were involved in the development of the plan of care. There were no signatures on the document. The hospice agency failed to ensure all IDG members were involved in the development of the plan of care for Patient 5. 4. During a review of Patient 6's ";Patient Face Sheet", indicated a start of care date (SOC) on 6/27/23 with a diagnosis of malignant neoplasm of bladder (cancer in the bladder). During a concurrent interview and record review on 10/13/23, at 10:51 a.m., the Director of Nursing designee (DD) reviewed Patient 6s record titled, ";Divine Intervention Hospice Inc.", dated 6/27/23. DD stated Patient 6 was imminently dying when he was admitted. The DD stated there was no bereavement assessment (assessing participants and grieving families to ensure that appropriate bereavement services are provided through the continuum of care from enrollment through the year following the death of the participant) and care plan because the nurses forgot to document it. The DD stated there was no bereavement care plan because it was not identified. DD stated Patient 6 passed away on 6/29/23 and there was no evidence a post bereavement care plan was done and implemented. DD stated a post bereavement care plan was important to ensure a follow up was done once the patient passed away. 5. During a review of Patient 9s medical record form titled ";Patient Face Sheet" indicated Patient 9 had a Start of Care (SOC) date of 6/30/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow to the heart due to plaque buildup). During a review of Patient 9s medical record form titled ";Physician Order Details" dated 6/30/2023, indicated ";SN (skilled nurse) visit once a week". During an interview on 10/13/2023 at 10:12 a.m., with the Director of Nurses (DON), the DON stated that if a patient has a missed visit the patient is contacted to reschedule, to continue to follow the weekly nursing visits. During a concurrent interview and record review on 10/13/2023 at 11:27 a.m. with LVN2 of Patient 9s electronic medical record (EMR), LVN2 stated the skilled nursing home visit frequency was once a week. LVN2 was unable to locate nursing documentation for the week of 9/10/2023. LVN2 stated that there was a missed visit that week and was unable to locate any documentation on the attempts to contact the patient. LVN2 stated, ";We dont know why there was a missed visit, we dont have a note from the nurse. The nurse was supposed to make a phone call to reschedule. If we dont get an answer, we do a physical visit, if there is no contact. We then call the family; we inform the doctor of the missed visit. For this case the doctor was not informed." A review of Patient 9s medical record form titled ";Certification of Plan of Care" dated 8/25/2023, indicated, ";SN visits 1st week: 1x visits... Following Weeks: 1x visits/week..." It also sections ";Hospice Physician Signature & RN Signature" were left empty. During a review of the hospice agencys (HA) policy and procedure titled, ";IDG Care Planning Process", dated January 2020, indicated, ";Procedure:...2. The care of plan specifies the care and services necessary to meet the patient and family-specific needs identified in the comprehensive assessment as such needs related to the terminal illness and related conditions." During a review of the HAs policy and procedure titled, ";IDG Care Planning Process", dated January 2020, indicated, ";Procedure: 1. Hospice has designated an interdisciplinary group which, in consultation with the patients attending physician, prepares a written plan of care for each patient. The group consist of: A physician member, Registered nurse, Social worker, pastoral or other counselor."

Based on interview, and record review, the hospice agency failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) review and update the plan of care at least every 15 days, for thirteen of fourteen sample patients (Patients 1, 2, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, and 14). This deficient practice had the potential to result in delay of patient care by not identifying the needs of the patient and revise the plan of care to meet those needs. --- During an interview on 10/11/2023, at 2 p.m., with Director of Nurses Designee (DD), the DD stated that interdisciplinary (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) team meetings are held every two weeks via zoom (online). The DD stated that the IDT members included a Registered Nurse (RN), Spiritual Counsellor (SC), Medical Social Worker (MSW), and Medical Director (MD) and that all had access to their Electronic Medical Record (EMR) system. The DD stated that all attendees of the IDT meetings need to sign, date of the meeting, which will indicate as an ";e-sign". The DD stated that the attendees signatures indicate they understood, agreed, and validated patients specific plan of care. The DD stated that the last IDT meeting was held on 9/19/2023. During an interview on 10/13/2023 at 1:07 p.m., with the Director of Nurses (DON), DON stated that the IDT meetings are being held on the same day of the patients admission with the core members, which included RN, MSW, MD and Chaplain. The DON stated that all members need to participate in the IDT meetings to be able to meet the patients needs. The DON stated that DD was responsible to attend the IDT meetings. DON stated ";IDT are important in order for the core team to know what is going on with the patient. If the IDT does not occur every 14 days, then we would not be able to meet the needs of the patients. If the patient needs are not met, the patient can be neglected. The DON stated that members sign the IDT meetings via their EMR the same day the meeting is held. During a telephone interview on 10/13/2023 at 1:07 p.m., with the Chaplain (SC), the SC stated he participated in the IDT meetings via zoom. The SC stated that they discuss the patients conditions to see if there were any changes in condition. The SC stated that he has access to the hospice agencys (HA) EMR where he documents his discussion and signs the IDT meeting. The SC stated that his signature validates his input. SC stated that the HAs last IDT meeting was held a week ago, and that the meetings are held every Tuesday. During a telephone interview on 10/13/2023 at 1:21 p.m., with the MSW, the MSW stated that she visits the patients within five days of admission and are discussed in the IDT meetings. MSW stated that she enters her input and electronically signs within two days of the meeting in the HAs EMR. MSW stated that she was on vacation for the past two week and that the last time she attended an IDT meeting was sometime in the middle of September. 1. A review of Patient 1's ";Patient Face Sheet", indicated a start of care date (SOC) on 12/13/22, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review, on 10/13/23 at 12:45 p.m. with the Director of Nursing Designee (DD) of Patient 1s clinical record titled, ";Interdisciplinary Team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) Plan of Care & Review of Comprehensive Assessment", dated 8/22/23, the DD stated the document indicated the names of the IDG members (Registered Nurse (RN), Spiritual Counsellor (SC), Medical Social Worker (MSW), and Medical Director (MD). The DD stated there were no signature of any IDG members on the document. The signatures would validate the attendance and input in the meeting. A record review of Patient 1s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 9/5/23, 9/19/23 and 10/3/23, did not indicate the RN, MSW, SC, and MD participated in reviewing and updating the patient's plan of care. There were no signatures that could validate their attendance and input in the meeting. 2. A review of Patient 2's ";Patient Face Sheet", indicated a start of care date (SOC) on 7/20/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). A record review of Patient 2s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 7/25/23, 8/8/23, 8/22/23, 9/5/23, 9/19/23 and 10/3/23, did not indicate the RN, MSW, MD, and SC participated in reviewing and updating P2s plan of care. There were no signatures to validate their attendance and input in the meeting. A record review of Patient 2s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 8/8/23, did not indicate the RN, MSW, MD, and SC participated in reviewing and updating the patient's plan of care. There were no signatures that could validate their attendance and input in the meeting. 3. A review of Patient 3's ";Patient Face Sheet", indicated a start of care date (SOC) on 9/18/23, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). A record review of Patient 3s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 9/19/23, 10/13/23, did not indicate the RN, MSW, MD, and SC participated in reviewing and updating the patient's plan of care. There were no signatures that could validate their attendance and input in the meeting. 4. A review of Patient 4's ";Patient Face Sheet", indicated a start of care date (SOC) on 4/22/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). A record review of Patient 4s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 8/8/23, 8/22/23, 9/19/23, 10/3/23, did not indicate the RN, MSW, MD, and SC participated in reviewing and updating patients plan of care. There were no signatures that could validate their attendance and input in the meeting. 5. A review of Patient 5's ";Patient Face Sheet", indicated a start of care date (SOC) on 9/27/23 with a diagnosis of hypertensive heart disease without heart failure (high blood pressure). A record review of Patient 5s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 10/3/23, did not indicate the RN, MSW, MD, and SC participated in reviewing and updating Patient 5s plan of care. There were no signatures that could validate their attendance and input in the meeting. 6. A review of Patient 6's ";Patient Face Sheet", indicated a start of care date (SOC) on 6/27/23 with a diagnosis of malignant neoplasm of bladder (cancer in the bladder). During a concurrent interview and record review on 10/13/23, at 10:51 a.m., DD reviewed Patient 6s record titled, ";Divine Intervention Hospice Inc.", dated 6/27/23. DD stated Patient 6 was imminently dying when he was admitted. DD stated there was no initial bereavement assessment (assessing participants and grieving families to ensure that appropriate bereavement services are provided through the continuum of care from enrollment through the year following the death of the participant) and care plan because the nurses forgot to document it. DD stated the bereavement needs were not identified. DD stated Patient 6 passed away on 6/29/23. A record review of Patient 6s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 7/11/23, did not indicate the RN, MSW, MD, and SC participated in reviewing and updating the plan of care. There were no signatures to validate their attendance and input in patient's care. Further review of the record indicated, ";Spiritual Care Report: Patient has expired (passed away) 6/29/23 at 7:11 p.m. SW (social worker) report: Patient has expired 6/29/23 at 7:11 p.m. Further review of the record did not have evidence a post bereavement plan was discussed. 7. A review of Patient 7's ";Patient Face Sheet", indicated a start of care date (SOC) on 4/15/23 with a diagnosis of unspecified heart disease. A record review of Patient 7s document titled, ";IDT Plan of Care & Review of Comprehensive Assessment", dated 4/18/23, 5/2/23, 5/16/23, 5/30/23, 6/13/23, did not indicate the RN, MSW, MD, and SC participated in reviewing and updating the plan of care. There were no signatures that could validate their attendance and input in the meeting. 8. A review of Patient 8s medical record form titled ";Patient Face Sheet" indicated P8 had a Start of Care (SOC) date of 12/6/2022 with diagnoses including hypertensive heart disease without heart failure (heart changes due to long term uncontrolled high blood pressure). During a concurrent interview and record review on 10/11/2023 at 2:07 p.m., with Director of Nurses Designee (DD) of Patient 8s Electronic Medical Record (EMR), DD stated the IDT meetings dated 8/22/2023, 9/5/2023, 9/19/2023, and 10/3/2023 were not signed. During a concurrent interview and record review on 10/13/2023 at 12:20 p.m. with License Vocational Nurse 2 (LVN2) of Patient 8s EMR, LVN2 stated the IDT meetings dated 9/19/2023 and 10/3/2023 were not signed by the IDT members. A review of Patient 8s medical record form titled ";Initial Assessment" dated 12/6/2022, indicated ";Coordination of Care – Collaboration with: MSW (Medical Social Worker), Medical Director, and attending physician and indicated it was signed by RN2. A review of Patient 8s medical record form titled ";IDT (Interdisciplinary Team) Plan of Care & Review of Comprehensive Assessment" dated 8/22/2023, 9/5/2023, 9/19/2023, and 10/3/2023, did not indicate all of the IDT teams signatures. 9. A review of Patient 9s medical record form titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 6/30/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow to the heart due to plaque buildup). During a concurrent interview and record review on 10/13/2023 at 11:27 a.m., with LVN2 of Patient 9s EMR, LVN2 stated IDT meetings 7/25/2023, 8/8/2023, and 8/22/2023 were not signed by the IDT members. LVN2 stated, ";The team who review must be on the same page and be aware of any changes with the patients to be able to provide the care that the patient needs." LVN2 stated that patients plan of care are based on the IDT meeting discussions and if the patients plan of care is not revised or updated, the hospice agency would not be able to address the changes in the care and provide for the patients needs. LVN2 stated that the patients care, and needs would be affected. LVN2 stated, ";we could be harming the patient." A review of Patient 9s medical record form titled ";Initial Assessment" dated 6/30/2023, indicated, ";Coordination of Care – Collaboration with: MSW, Medical Director, and attending physician. Form also indicated it was signed by DD. A review of P9s medical record form titled ";IDT Plan of Care & Review of Comprehensive Assessment" dated 7/11/2023, 7/25/2023, 8/8/2023, 8/22/2023, 9/5/2023, 9/19/2023, and 10/3/2023, ";The following IDT members updated / reviewed the interdisciplinary Team Plan of Care", however, it did not indicate all of the IDT teams signatures. 10. A review of Patient 10s medical record form titled ";Patient Face Sheet" indicated Patient 10 had a Start of Care (SOC) date of 9/21/2023 with diagnoses heart disease unspecified (inability of the heart to pump blood adequately). During a concurrent interview and record review on 10/11/2023 at 2:48 p.m., with the DD of Patient 10s EMR, the DD stated the last IDT meeting was held on 10/17/2023, however, there were no signatures of any of the IDT members. A review of Patient 10s medical record form titled ";Initial Assessment" dated 9/21/2023, indicated ";Coordination of Care – Collaboration with: MSW, Medical Director, and attending physician. The form indicated a signature of RN3. 11. A review of Patient 11s medical record form titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 5/3/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow to the heart due to plaque buildup). During a concurrent interview and record review on 10/13/2023 at 2:30 p.m. with LVN2 of Patient 11s EMR, LVN2 stated IDT meetings dated 10/3/2023, 9/5/2023, and 9/19/2023, did not indicate the IDT teams signatures. A review of Patient 11s medical record form titled ";Initial Assessment" dated 9/28/2023, indicated, ";Coordination of Care – Collaboration with: Medical Director, and attending physician. The form indicated a signature of the DD. 12. A review of Patient 12s medical record form titled ";Patient Face Sheet" indicated Patient 12 had a Start of Care (SOC) date of 12/6/2022 with diagnoses including unspecified psychosis not due to a substance or known physiological condition (loss of touch with reality and may involve hallucinations, delusions, disordered thinking, and behavioral changes). During a concurrent interview and record review on 10/13/2023 at 3:20 p.m., with LVN2 of Patient 12s EMR, LVN2 stated the IDT meetings dated 9/5/2023, 9/19/2023, and 10/3/2023 were not signed by the IDT members. LVN2 stated that if the document was not signed it means it was not done. A review of Patient 12s medical record form titled ";Initial Assessment" dated 12/6/2023, indicated, ";Coordination of Care – Collaboration with: MSW, Medical Director, and attending physician. The form indicated it was signed by RN2. A review of Patient 12s medical record form titled ";IDT Plan of Care & Review of Comprehensive Assessment" dated 8/8/2023, 8/22/2023, 9/5/2023, 9/19/2023, and 10/3/2023 indicated, ";The following IDT members updated / reviewed the interdisciplinary Team Plan of Care", however, the document had no IDT members signatures. 13. A review of Patient 13s medical record form titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 2/20/2023 and an End of Care (EOC) date of 6/30/2023, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one‐sided weakness, but without complete paralysis). During a concurrent interview and record review on 10/13/2023 at 4 p.m. with LVN2 of Patient 13s EMR, LVN2 stated the IDT meeting dated 6/13/2023 were not signed by the IDT members. LVN2 stated that if the document was not signed, it was not done. A review of Patient 13s medical record form titled ";Initial Assessment" dated 2/20/2023, indicated, ";Coordination of Care – Collaboration with: MSW, Medical Director, and attending physician. The form indicated it was signed by the DD. A review of Patient 13s medical record form titled ";IDT Plan of Care & Review of Comprehensive Assessment" dated 5/16/2023, 5/30/2023, 6/13/2023, 6/27/2023, and 7/11/2023, indicated ";The following IDT members updated / reviewed the interdisciplinary Team Plan of Care", however, the document had no IDT members signatures. 14. A review of Patient 14s medical record form titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 1/14/2023 and an End of Care (EOC) date of 8/16/2023, with diagnoses including atherosclerotic heart disease of native coronary artery with unstable angina pectoris (reduced blood flow to the heart due to plaque buildup). A review of Patient 14s medical record form titled ";IDT Plan of Care & Review of Comprehensive Assessment" dated 6/27/2023, 7/11/2023, 7/25/2023, and 8/8/2023, indicated ";The following IDT members updated / reviewed the interdisciplinary Team Plan of Care", however, the document had no IDT members signatures. A review of the hospice agencys policy and procedure titled, ";IDG Care Planning Process", dated January 2020, indicated, ";The IDG reviews, revises, and documents the individualized plan as frequently as the patients condition requires, but no less frequently than every 15-calendar day. The revised plan of care includes information from the patients updated comprehensive assessment and notes the patients progress towards outcomes and goals specified in the plan of care, advance directives, effectiveness of pain and symptom management, and spiritual and psychosocial needs".

Based on interview and record review the Hospice Agency (HA) failed to ensure two of fourteen sampled patients (Patient 6, and Patient 13) had bereavement counseling services after patients' passing (postmortem). This failure resulted in families/care givers did not receive the bereavement services after their family member passed away. --- Findings: A review of Patient 6's ";Patient Face Sheet", indicated a start of care date (SOC) on 6/27/23 with a diagnosis of malignant neoplasm of bladder (cancer in the bladder). During a concurrent interview and record review on 10/13/23, at 10:51 a.m., the Director of Nursing designee (DD) reviewed Patient 6s record was reviewed and DD stated Patient 6 was imminently dying when he was admitted. DD stated there was no bereavement assessment and care plan because the nurses forgot to document it. DD stated there was no bereavement care plan because it was not identified. DD stated Patient 6 passed away on 6/29/23, and there was no evidence a post bereavement care plan was done and implemented. There was no evidence the HA provided post-bereavement care to Patient 6s family/caregiver. There was no documentation the Medical Social Worker and Spiritual Counselor offered the availability of the bereavement services to reflect the needs of the bereaved. DD stated a post bereavement care plan was important to ensure a follow up was done once the patient passed away. During an interview on 10/13/2023 at 1:07 p.m., with the Director of Nurses (DON), DON stated that the SC was responsible for the post bereavement. DON stated that the SCs responsibility was to ";uplift their emotional feelings of the family.:" DON stated that the SC calls the family on the same day the patient passes away, to console them. DON stated that it was important for the SC to console the families spiritually and emotionally. During a telephone interview on 10/13/2023 at 1:07 p.m., with the Chaplain (SC), SC stated he was the bereavement coordinator. During a telephone interview on 10/13/2023 at 1:21 p.m. with the Medical Social Worker (MSW), MSW stated that after a patients death, the HA sends the family condolences letters. MSW stated that the families usually reach out to the SC, post bereavement. A review of Patient 13s medical record form titled ";Patient Face Sheet" indicated Patient 13 had a Start of Care (SOC) date of 2/20/2023 and an End of Care (EOC) date of 6/30/2023, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one‐sided weakness, but without complete paralysis). During a concurrent interview and record review on 10/13/2023 at 4 p.m., with License Vocational Nurse 2 (LVN2) of Patient 13s Electronic Medical Record (EMR), LVN2 stated that there was a note stating that the SC will be sending out bereavement letters. LVN2 stated that there was nothing documented for the post bereavement services for Patient 13. LVN2 stated ";There is nothing documented, there is no follow up." A record review of the HAs undated policy and procedure titled, ";Bereavement Services", indicated, ";Procedure 1. A bereavement risk assessment will be completed by the hospice social worker at the time of admission to hospice...2. After the bereavement risk assessment is completed, a plan will be developed to address bereavement/grief issues and will be implemented and updated as needed...5. After a death has occurred, the bereavement assessment will be updated and the family caregiver needs will be discussed at the next interdisciplinary group meeting...8.Within two (2) weeks after the death of a patient, a sympathy card will be sent to the bereaved. 9. After three (3) weeks, a bereavement letter will be sent to the bereaved, offering support and outlining the hospice bereavement services...13. A bereavement file will be maintained on each family/caregiver unit of care. Each file will contain the following information: A. Copy of the patient referral and initial bereavement assessment. B. Bereavement service report. C. All bereavement assessments made. D. A bereavement plan of care."

Based on observation, interview, and record review, the hospice agency failed to meet the Condition of Participation for Medical Director as follows: --- 1. The hospice agency failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice), reviewed the patients clinical information to determine hospice care (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) criteria were met, and/or had provided an initial written certification of terminal illness that the patient had six months or less to live if the illness runs its normal course, for fourteen of fourteen sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14). (Refer to L 667). 2. The Hospice Agency failed to ensure the medical director and/or physician designee conducted a review and verified the patients clinical information to determine, if eight of fourteen sampled patients (Patients 1, 4, 8, 9, 11, 12, 13 and 14), have met the criteria and needed recertification of terminal illness to continue hospice care and services. (Refer to L 668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on interview and record review, the hospice agency failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice), reviewed patients clinical information to determine hospice care (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) criteria were met, and/or provided an initial written certification of terminal illness that the patient had six months or less to live if the illness runs its normal course, for fourteen of fourteen sample patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14). These deficient practices resulted in the hospice medical director and/or the designee certifying these patients to receive hospice care benefits without clinical evidence to support the terminal illness diagnoses. --- During a telephone interview on 10/13/2023, at 4 p.m., with the Medical Director 1 (MD1), MD1 stated he was contracted as the hospice agencys (HA) Medical Director for a ";few years". MD1 stated that he provides medical guidance and stated the HA presents him with a patient and they send the patients certification of terminal Illness (CTI, illness with a prognosis of having 6 months of life or less) or the re-certifications to him. MD1 stated that he attends interdisciplinary team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings every two weeks. MD1 stated that the patients evaluation, the physician narratives of the CTI form is being completed and documented by the hospice Nurse Practitioner (NP) and the nurse, then he reviews the patients information, goes over the CTIs, and signs them. MD1 stated that he receives patients CTI via fax from the hospice agency, then he (MD1) signs the CTI and faxes it back to the hospice agency within a week. MD1 stated, ";A lot of these patients do have primary care physician (PCP), occasionally we speak with their PCPs when we have questions or concerns." During an interview on 10/13/2023, at 10:12 a.m., with the Director of Nurses (DON), the DON stated that the CTI is completed and signed by the MD upon admission to certify that a patient meets hospice criteria. DON stated that the MD signature indicates he is certified that the patient is terminal (with 6 months or less to live). The DON stated that if there was no documented CTI, the HA would be unable to proceed with a patients plan of care. DON stated that the MD needed to see the patient before their third recertification period. A review of Patient 1's ";Patient Face Sheet", indicated a start of care date (SOC) on 12/13/22, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/23, at 12:15 p.m., the Director of Nursing Designee (DD) reviewed Patient 1s CTI, dated 12/13/22, the DD stated the record did not indicate that the doctor had signed the CTI document. DD also stated that the doctors signature would validate that the patient was qualified for hospice care. The DD also stated the doctor was supposed to certify the patient on the day of admission. During a concurrent interview and record review on 10/13/23, at 1:53 p.m., DD reviewed Patient 1s record titled, ";Certification of Terminal Illness", dated 12/13/22. The record indicated a verbal certification order was obtained from the doctor on 12/13/22. DD stated the document did not indicate the name and signature of the nurse who obtained the certification order. During an interview on 10/13/23, at 1:55 p.m., DD stated the clinical records did not contain medical documents such as history and physical (describes the medical history, current illness, and treatment plan), laboratory results, or any documents from the previous doctor or hospital, to support Patient 1s admitting diagnosis. The only validation of Patient 1s terminal illness was the initial comprehensive assessment from the nurse. During an interview on 10/13/23, at 4:03 p.m., the Medical Director (MD) stated he was responsible in reviewing medical information to determine if patients qualified (certify) and re-qualified (re-certify) for hospice care. The MD stated the evaluation was done by the hospice nurse and the nurse practitioner. The MD stated once appropriateness was determined, he verified the information and proceeded from there. The MD stated he did not have access to the electronical documentation system to sign the documents electronically, he relied on the diagnosis and symptoms to determine hospice eligibility and used X-rays, H&P, recent hospitalizations, recent diagnostic images, or any documents provided, to support the diagnosis. A review of Patient 2's ";Patient Face Sheet", indicated a start of care date (SOC) on 7/20/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/23, at 2:10 p.m., the DD reviewed Patient 2s record titled, ";Certification of Terminal Illness (CTI)", dated 7/20/23 and the record did not indicate the doctor had signed the document. DD stated the doctors signature would have validated Patient 2 was qualified for hospice care. During an interview on 10/13/23, at 2:10 p.m., DD stated Patient 2 was qualified for hospice care due to his heart disease and symptoms, however, there was no H&P or any other documents to support the patient's diagnosis. A review of Patient 3's ";Patient Face Sheet", indicated a start of care date (SOC) on 9/18/23, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/23, at 2:20 p.m., DD reviewed Patient 3s record titled, ";Certification of Terminal Illness (CTI)", dated 9/18/23, however, the record did not indicate the doctor had signed the document. The DD stated the doctors signature would have validated the patient was qualified for hospice care. During an interview on 10/13/23, at 2:20 p.m., the DD stated Patient 3 qualified for hospice care due to his heart disease, uncontrolled blood pressure, and cholesterol problems, however, the DD stated there was no H&P, laboratory results or other medical documents to support the patient's diagnosis. A review of Patient 4s ";Patient Face Sheet" indicated a start of care date (SOC) on 4/22/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). A record review of Patient 4s document titled, ";Certification of Terminal Illness (CTI)", dated 4/22/23, did not indicate the MD certified the patient for hospice care. The MDs signature was missing. A review of Patient 5s ";Patient Face Sheet" indicated a start of care date (SOC) on 9/27/23 with a diagnosis of hypertensive heart disease without heart failure (high blood pressure). A record review of Patient 5s document titled, ";Certification of Terminal Illness (CTI)", dated 9/27/23, did not indicate the MD certified Patient 5 for hospice care. The MDs signature was missing. A review of Patient 6s ";Patient Face Sheet" indicated a start of care date (SOC) on 6/27/23 with a diagnosis of malignant neoplasm of bladder (cancer in the bladder). A record review of Patient 6s document titled, ";Certification of Terminal Illness (CTI)", dated 6/27/23, did not indicate the MD certified P6 for hospice care. The MDs signature was missing. A review of Patient 7's ";Patient Face Sheet", indicated a start of care date (SOC) on 4/15/23 with a diagnosis of unspecified heart disease. A record review of Patient 7s document titled, ";Certification of Terminal Illness (CTI)", dated 4/15/23, did not indicate the MD certified Patient 7 for hospice care. The MDs signature was missing. A review of Patient 8s medical record form titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 12/6/2022 with diagnoses including hypertensive heart disease without heart failure (heart changes due to long term uncontrolled high blood pressure). During a concurrent interview and record review on 10/11/2023 at 2 p.m. with the DD of Patient 8s EMR, the DD stated that Patient 8s first CTI dated 12/6/2022, was not signed by the MD1. DD stated that the form would have stated ";e-sign" if MD1 had signed it. The DD stated that the CTI indicates that the doctor certifies the patient for hospice care. DD stated that the initial CTI needed to be signed by MD1 within five days of admission. During a joint home visit on 10/12/2023 at 12:10 p.m., with the DD to Patient 8s home, Patient 8 was awake, oriented, ambulatory, and managed his own meds. Patient 8 was noted sitting on dining room chair, fully clothed with shoes on. During a concurrent interview, Patient 8 stated that hospice is a program for patients that have ";certain conditions" that may cause death. Patient 8 also stated that they provided medications, wipes, lotions, and had saw his primary doctor about one and a half weeks ago at his Clinic. Patient 8 stated that he was not told that he had six months or less to live by any doctor. During a telephone interview to be conducted on 10/12/2023 at 1:45 p.m., a call was placed to the clinic for Patient 8s PCP. Female personnel answered the phone, and a message was left for Patient 8s PCP. A phone number was provided for the PCP to call back. During a concurrent interview and record review on 10/13/2023 at 12;20 p.m. with License Vocational Nurse 2 (LVN2), for Patient 8s Electronic Medical Record (EMR), LVN2 stated the initial CTI dated 12/6/2022 was not signed by MD1. A review of Patient 8's medical record form titled ";Certification of Terminal Illness" dated 12/6/2022, indicated, ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The form indicated the MD1 name, however, the CTI form was not signed by MD1. A review of Patient 9s medical record form titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 6/30/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow to the heart due to plaque buildup). A review of Patient 9s medical record form titled ";Certification of Terminal Illness" dated 6/30/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The form indicated the MD1 name, however, the CTI form was not signed by MD1. During a joint home visit on 10/12/2023 at 10:30 a.m., with the DD to Patient 9s home, DD stated the patient lives alone, manages her own medication, is continent, awake and alert. Patient 9 was observed ambulating well, was fully dressed, and was holding her cell phone. Patient 9 stated that she goes to the nail salon to do her nails frequently and the last time was a month ago. Patient 9 stated that she walks to church every Sunday. Patient 9 stated that she left her medications and hospice binder at her sons house where she spent the night last night. Patient 9 stated that she has a pr imary doctor that she has been with for the past 5 years. Patient 9 stated that she has an appointment soon with her Primary Doctor (PCP1). Patient 9 stated that there has not been a doctor who has told her that she has 6 months or less to live, stated that she wouldnt know what do if she heard that she would die in 6 months. During a telephone interview on 10/12/2023 at 11:30 a.m. with Patient 9s PCP1s Nurse (NM), NM stated that PCP1 has not referred Patient 9 for hospice care. NM stated that PCP1 was going to call Patient 9 to ";find out what was going on". During a concurrent interview and record review of Patient 9s EMR on 10/13/2023 at 11:27 a.m. with LVN2, LVN2 stated that the initial CTI dated 6/30/2023 was not signed by MD1. LVN2 stated that since the CTI was not signed by MD1, the patient was not certified by a doctor". A review of Patient 10s medical record form titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 9/21/2023 with diagnoses heart disease unspecified (inability of the heart to pump blood adequately). During a telephone interview on 10/13/2023 at 8:25 a.m., Patient 10 stated the HA provided shampoo, blood pressure machine and a glucometer (machine to check blood sugar). Patient 10 stated she had had been seeing PCP2 for five years and will see PCP2 on 10/23/2023 for blood draw and then again on 10/31/2023 to get the results. Patient 10 stated that she picks up her granddaughter from school daily, goes to a market and sometimes to get fast food, walks a lot, that sometimes to the beach. further stated that there has never been a doctor who has told her she had six months or less to live. During a telephone interview on 10/13/2023 at 8:34 a.m. with Patient 10s Primary Doctors Nurse (BM), BM stated that PCP2 had been seeing and treating Patient 10 for the past five years and the next appointment was on 10/23/2023 for a blood draw, then on 10/31/223 to see PCP2. BM stated that the patient had been referred for physical therapy, but not for hospice care. BM stated ";I dont see a hospice referral. She hasnt even been admitted to a hospital. Usually hospice patients are bed-bound, she is not. There are no hospice referrals." During a concurrent interview and record review of Patient 10s EMR on 10/13/2023 at 1:50 p.m. with LVN2, LVN2 stated the initial CTI dated 9/21/2023 was not signed by MD1. LVN2 stated ";again, the patient was not certified by a doctor". A review of Patient 10s medical record form titled ";Certification of Terminal Illness" dated 9/21/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI form indicated MD1s name, however, it did not indicate it was signed by MD1. A review of Patient 11s medical record form titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 5/3/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow to the heart due to plaque buildup). During a concurrent interview and record review of Patient 11s EMR on 10/13/2023 at 2:30 p.m. with LVN2, LVN2 stated the initial CTI dated 5/3/2023 was not signed by MD1. LVN2 stated that MD1 needed to sign the CTIs. LVN2 stated, ";If it was not signed, that means the patient was not certified for hospice services." A review of Patient 11s medical record form titled ";Certification of Terminal Illness" dated 5/3/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI form indicated MDs name, however, the form was not signed by MD1. During a concurrent interview and record review of Patient 11s initial CTI on 10/13/2023 at 3:20 p.m. with LVN2, the initial CTI dated 12/6/2022 was completed but not signed by MD1. LVN2 stated that she does not know why MD1 does not sign. A review of Patient 12s medical record form titled ";Patient Face Sheet", indicated a Start of Care (SOC) date of 12/6/2022, with diagnoses including unspecified psychosis not due to a substance or known physiological condition (loss of touch with reality and may involve hallucinations, delusions, disordered thinking, and behavioral changes). A review of Patient 12s medical record form titled ";Certification of Terminal Illness" dated 12/6/2022, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI form indicated MDs name, however, the form was not signed by MD1. A review of Patient 13s medical record form titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 2/20/2023 and an End of Care (EOC) date of 6/30/2023, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one‐sided weakness, but without complete paralysis). During a concurrent interview and record review on 10/13/2023 at 4 p.m. with LVN2, LVN2 stated Patient 13s initial CTI dated 2/20/2023, was completed but was not signed by MD1. A review of Patient 13s medical record form titled ";Certification of Terminal Illness" dated 2/20/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI form indicated MDs name, however, the form was not signed by MD1. A review of Patient 14s medical record form titled ";Patient Face Sheet" indicated a Start of Care (SOC) date of 1/14/2023 and an End of Care (EOC) date of 8/16/2023, with diagnoses including atherosclerotic heart disease of native coronary artery with unstable angina pectoris (reduced blood flow to the heart due to plaque buildup). A review of Patient 14s medical record form titled ";Certification of Terminal Illness" dated 1/14/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI form indicated MDs name, however, the form was not signed by MD1. A review of the HAs undated document titled, ";Job Description Medical Director", indicated, ";The Medical Director or physician designee reviews the clinical information for each Hospice patient and provides written certification that it is anticipated that the patients life expectancy is 6 months or less if the illness runs its normal course." A review of the HAs policy and procedure titled, ";Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluations", dated June 2019, indicated, ";In order to be eligible to elect Hospice care under Medicare, a patient must be certified as being terminally ill; Hospice will obtain the written certification no later than two (2) calendar days after the period begins; The Medical Director or physician designee reviews the clinical information and other documentation that supports the medical prognosis for each Hospice patient. This Brief Narrative Statement must accompany the certification and be filed in the patient record."

Based on interview and record review, the Hospice Agency failed to ensure the medical director and/or physician designee conducted a review and verified the patients clinical information to determine if eight of fourteen sampled patients, (Patients 1, 4, 8, 9, 11, 12, 13 and 14), needs recertification of terminal illness to continue the hospice care and services. This deficient practice resulted in the hospice agency claiming reimbursements for patients who would have not needed or did not meet the recertification criteria for hospice care and services. --- During an interview on 10/13/2023 at 10:12 a.m. with the Director of Nurses (DON), DON stated that a Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less) is completed and signed by the Medical Director (MD1) upon admission to certify that a patient meets hospice criteria. DON stated that an MD1 signature indicates he is certifying a patient is terminal. DON stated that if there was no documented CTI, the hospice agency (HA) was unable to proceed with a patients plan of care. DON stated that the MD needed to see a patient before their third recertification period. During an interview on 10/12/2023 at 1:15 p.m. with the Director of Nurse Designee (DD), DD stated, ";Hospice is a program from Medicare, where a patient is certified with a terminal condition." During a telephone interview on 10/13/2023, at 4 p.m., with the Medical Director 1 (MD1), MD1 stated he was contracted as the hospice agencys (HA) Medical Director for a ";few years". MD1 stated that he provides medical guidance and stated the HA presents him with a patient and they send the patients certification of terminal Illness or the re-certifications to him. MD1 stated that he attends interdisciplinary team (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings every two weeks. MD1 stated that the patients evaluation, the physician narratives of the CTI form is being completed and documented by the hospice Nurse Practitioner (NP) and the nurse, then he reviews the patients information, goes over the CTIs, and signs them. MD1 stated that he receives patients CTI via fax from the hospice agency, then he (MD1) signs the CTI and faxes it back to the hospice agency within a week. MD1 stated, ";A lot of these patients do have primary care physician (PCP), occasionally we speak with their PCPs when we have questions or concerns." MD1 stated he did not have access to the electronical documentation system to sign the documents electronically. A review of Patient 1s ";Patient Face Sheet" indicated a start of care date (SOC) on 12/13/22, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). A record review of Patient 1s document titled, ";Certification of Terminal Illness", dated 3/12/23, did not indicate the MD re-certified P1 for hospice care. There was no signature of the MD. There was no date of verbal certification. A record review of Patient 1s document titled, ";Certification of Terminal Illness", dated 6/10/23, 8/9/23, did not indicate the MD re-certified Patient 1 for hospice care. There was no signature of the MD. There was no date of verbal certification. The HA had provided hospice services to Patient 1 without being re-certified by the MD. A review of Patient 4s ";Patient Face Sheet" indicated a start of care date (SOC) on 4/22/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). A record review of Patient 4s document titled, ";Certification of Terminal Illness (CTI)", dated 7/20/23, did not indicate the MD re-certified Patient 4 for hospice care. The MDs signature was missing. The HA had provided hospice services to Patient 4 without being re-certified by the MD. A review of Patient 8s medical record form titled ";Patient Face Sheet" indicated Patient 8 had a Start of Care (SOC) date of 12/6/2022 with diagnoses including hypertensive heart disease without heart failure (heart changes due to long term uncontrolled high blood pressure). During a concurrent interview and record review on 10/13/2023 at 12:20 p.m. with License Vocational Nurse 2 (LVN2) of P8s Electronic Medical Record (EMR), LVN2 stated that Patient 8s CTIs dated 3/5/2023, 5/30/2023, 8/2/2023, and 9/29/2023, were not signed by MD1. LVN2 stated that MD1 needed to sign all the CTIs cause if they were not signed, it would mean Patient 8 was not certified for hospice care. A review of Patient 8s medical record form titled ";Certification of Terminal Illness" dated 3/5/2023, 5/30/2023, 8/2/2023, and 9/29/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." It also indicated the MD1 name, however, the form was not signed by MD1. During a concurrent interview and record review on 10/11/2023 at 2 p.m. with the DD of Patient 8s EMR, DD stated CTIs dated 3/5/2023, 5/30/2023, 8/2/2023, and 9/29/2023, were not signed by MD1. DD stated the CTIs would have said ";e-sign" if MD1 had signed the CTIs. DD stated, ";CTI should be signed, its where the doctor certifies that the patient is eligible for hospice." During a joint home visit on 10/12/2023 at 12:10 p.m. with the DD to Patient 8s home, Patient 8 was awake, oriented, ambulatory, and manages his own meds. Patient 8 was observed sitting on dining room chair, fully clothed with shoes on. Patient 8 stated that hospice was a program for patients that have ";certain conditions" that may cause death. Patient 8 also stated that they provide medications, wipes, and lotions. Patient 8 stated that he saw his primary doctor about one and a half weeks ago at his Clinic. Patient 8 stated that he has not been told that he had six months or less to live by any doctor. A review of Patient 9s medical record form titled ";Patient Face Sheet" indicated Patient 9 had a Start of Care (SOC) date of 6/30/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow to the heart due to plaque buildup). During a joint home visit on 10/12/2023 at 10:30 a.m. with the DD to Patient 9s home, Patient 9 lives alone, manages her own medication, is continent, and the Patient 9 was awake and alert. Patient 9 greeted us at the door, escorted us into her rented room. Patient 9 was ambulating well, was fully dressed, and was holding her cell phone. Patient 9 stated that she goes to the nail salon to do her nails frequently, last time was a month ago. Patient 9 looked on her phone and offered nail salons name and phone number. Patient 9 stated that she walks to church every Sunday. Patient 9 stated that she left her medications and hospice binder at her sons house where she spent the night last night. Patient 9 stated that she has a primary doctor that she has been with for the past 5 years. Patient 9 stated that she has an appointment soon with her Primary Doctor (PCP1). Patient 9 stated that there has not been a doctor who has told her that she has 6 months or less to live. Patient 9 stated that she wouldnt know what do if she heard that she would die in 6 months. During a concurrent interview and record review on 10/13/2023 at 11:27 a.m. with LVN2 of Patient 9s EMR, LVN2 stated that Patient 9s CTI dated 8/25/2023 was not signed by MD1. A review of Patient 9s medical record form titled ";Certification of Terminal Illness" dated 8/25/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI form indicated the MD1 name, however, the form was not signed by MD1. A review of Patient 11s medical record form titled ";Patient Face Sheet" indicated Patient 11had a Start of Care (SOC) date of 5/3/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (reduced blood flow to the heart due to plaque buildup). During a concurrent interview and record review on 10/13/2023 at 2:30 p.m. with LVN2 of Patient 11s EMR, LVN2 stated that Patient 11s initial CTIs dated 7/31/2023, 8/29/2023, and 9/28/2023, were not signed by MD1. LVN2 stated that MD1 needed to sign the CTIs, and stated, ";If it was not signed, that means the patient was not certified for hospice services." A review of Patient 11s medical record form titled ";Certification of Terminal Illness" dated 7/31/2023, 8/29/2023, and 9/28/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI form indicated MD1 name, however, the form was not signed by MD1. A review of Patient 12s medical record form titled ";Patient Face Sheet" indicated Patient 12 had a Start of Care (SOC) date of 12/6/2022 with diagnoses including unspecified psychosis not due to a substance or known physiological condition (loss of touch with reality and may involve hallucinations, delusions, disordered thinking, and behavioral changes). During a concurrent interview and record review on 10/13/2023 at 3:20 p.m. with LVN2 of Patient 12s EMR, LVN2 stated that Patient 12s initial CTIs dated 3/5/2023, 6/3/2023, 8/2/2023, and 9/21/2023 were completed but were not signed by MD1. A review of Patient 12s medical record form titled ";Certification of Terminal Illness" dated 3/5/2023, 6/3/2023, 8/2/2023, and 9/21/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI form indicated MD1 name, however, the form was not signed by MD1. A review of Patient 13s medical record form titled ";Patient Face Sheet" indicated Patient 13 had a Start of Care (SOC) date of 2/20/2023 and an End of Care (EOC) date of 6/30/2023, with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one‐sided weakness, but without complete paralysis). During a concurrent interview and record review on 10/13/2023 at 4 p.m. with LVN2 of Patient 13s EMR, LVN2 stated that Patient 13s initial CTI dated 5/20/2023 was completed but not signed by MD1. A review of Patient 13s medical record form titled ";Certification of Terminal Illness" dated 5/20/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI form indicated MD1 name, however, the form was not signed by MD1. A review of Patient 14s medical record form titled ";Patient Face Sheet" indicated Patient 14 had a Start of Care (SOC) date of 1/14/2023 and an End of Care (EOC) date of 8/16/2023, with diagnoses including atherosclerotic heart disease of native coronary artery with unstable angina pectoris (reduced blood flow to the heart due to plaque buildup). A review of Patient 14s medical record form titled ";Certification of Terminal Illness" dated 4/13/2023, indicated ";I confirm that this narrative was composed by me and is based on my review of the patients medical record and/or examination of the patient." The CTI form indicated MD1 name, however, the form was not signed by MD1. A review of the HAs policy and procedure titled, ";Certification/Recertification of Terminal Illness, Brief Narrative Statement and Face-to-Face Evaluations", dated June 2019, indicated, ";For subsequent periods, the only requirement is recertification by either the Medical Director or physician designees review of patients clinical information. Recertification is completed no later than two (2) calendar days after the first day of each benefit period, and no more than fifteen (15) days before the next benefit period begins."

Based on interview and record review, the Hospice Agency failed to meet the Condition of Participation on Clinical Records as follows: --- 1. The hospice agency failed to ensure the clinical records, ";Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less)", for seven of fourteen sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7), were completed and signed by the Medical Director or designee. This failure had the potential to result in an unauthorized and inaccurate patient information or assessments, entered in the patients clinical record that could affect the patients quality of care and services provided to the affected patients. (Refer to L679). 2. The Hospice Agency failed to ensure contents and information in the patients medical records, for seven of fourteen sample selected patients (Patients 1, 2, 3, 4, 5, 6, and 7), were safeguarded against unauthorized access by any hospice agency staff and/or contracted staff, to make any alterations or modifications. This failure had the potential to result in an unauthorized access and documentation of inaccurate patient information or assessment in the patients' clinical records that could affect the patients quality of care and well-being. (Refer to L680). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records are safeguarded from unauthorized access by any individuals or hospice staff.

Based on interview and record review, the hospice agency failed to ensure the clinical records, ";Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less)", for seven of fourteen sampled patients (Patients 1, 2, 3, 4, 5, 6, and 7), were completed and signed by the Medical Director or designee. This failure had the potential to result in an unauthorized and inaccurate patient information or assessments, entered in the patients clinical record that could affect the patients quality of care and services provided to the affected patients. --- A review of Patient s ";Patient Face Sheet", indicated a start of care date (SOC) on 12/13/22, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/23, at 12:15 p.m. with the Director of Nursing designee (DD), Patient 1s document titled, ";Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less)", dated 12/13/22 indicated, in the section ";Hospice Physician Written Certification", an attestation confirming the narrative was composed by the doctor, the DD stated this section should have been written by the doctor and a signature would validate the narrative was written. The DD stated that there was no signature on the document, and the clinical record failed to show the author of the note. During an interview on 10/13/2023, at 12:40 p.m., the DD stated one of the nurses had entered the information in the hospice physician narrative of the document, then the doctor would edit, finalize the narrative, and sign it. The DD stated she did not know who the nurse was who documented the narrative. During an interview on 10/13/2023, at 4:03 p.m., the Medical Director (MD) stated he did not have access to the electronical documentation system to sign the documents electronically. The MD also stated that the physician narrative section of the CTI was documented by the nurse practitioner or admitting nurse. A record review of Patient 1s document titled, ";Certification of Terminal Illness", dated 3/12/23, 6/10/23 and 8/9/23, indicated in the section ";Hospice Physician Written Certification", an attestation confirming the narrative was composed by the doctor. The document did not have the MD signatures. The clinical record failed to show the author of the note. A review of Patient 2's ";Patient Face Sheet", indicated a start of care date (SOC) on 7/20/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/23, at 2:10 p.m., with the DD, Patient 2s document titled, ";Certification of Terminal Illness", dated 7/20/23, indicated in the section ";Hospice Physician Written Certification" an attestation confirming the narrative was composed by the doctor. The DD stated this section was written by the admitting nurse. DD stated the document was not signed by the doctor. The clinical record failed to show the author of the note. A review of Patient 3's ";Patient Face Sheet", indicated a start of care date (SOC) on 9/18/23, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/23, at 2:20 p.m., with the DD, Patient 3s record titled, ";Certification of Terminal Illness", dated 9/18/23, indicated in the section ";Hospice Physician Written Certification" an attestation confirming the narrative was composed by the doctor. The DD stated this section was written by the admitting nurse. DD stated the document was not signed by the doctor. The clinical record failed to show the author of the note. A review of Patient 4s ";Patient Face Sheet", indicated a start of care date (SOC) on 4/22/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). A review of Patient 1s document titled, ";Certification of Terminal Illness", dated 7/20/23, indicated a narrative was documented in the section titled ";Hospice Physician Written Certification". The document did not indicate the author of the note. A review of Patient 5s ";Patient Face Sheet", indicated a start of care date (SOC) on 9/27/23 with a diagnosis of hypertensive heart disease without heart failure (high blood pressure). A review of Patient 5s document titled, ";Certification of Terminal Illness", dated 9/27/23, indicated a narrative was documented in the section titled ";Hospice Physician Written Certification". The document did not indicate the author of the note. A review of Patient 6s ";Patient Face Sheet", indicated a start of care date (SOC) on 6/27/23 with a diagnosis of malignant neoplasm of bladder (cancer in the bladder). A review of Patient 6s document titled, ";Certification of Terminal Illness", dated 6/27/23, indicated a narrative was documented in the section titled ";Hospice Physician Written Certification". The document did not indicate the author of the note. A review of Patient 7s ";Patient Face Sheet", indicated a start of care date (SOC) on 4/15/23 with a diagnosis of unspecified heart disease. A review of Patient 7s document titled, ";Certification of Terminal Illness", dated 4/15/23, indicated a narrative was documented in the section titled ";Hospice Physician Written Certification". The document did not indicate the author of the note. A review of the hospice agencys policy and procedure titled, ";Patient Record Entries: Authentication", dated June 2019, indicated, ";All entries in patient records will be legible, clear, complete, and appropriately authenticated, dated, and timed. It also indicated, all entries in the patient record will be authenticated by staff by signing first name or initial, last name and title. By authenticating the entries in the patients record, staff is validating the correctness of the information; If automated clinical record system is used, authentication includes a signature and titled or a secured computer entry by a unique identifier of a primary author who has reviewed and approved the entry, in accordance with state law."

Based on interview and record review, the Hospice Agency failed to ensure the contents and information in the patients medical records, for seven of fourteen sample selected patients (Patients 1, 2, 3, 4, 5, 6, and 7), were safeguarded against unauthorized access by any hospice agency staff and/or contracted staff, to make any alterations or modifications, This failure had the potential to result in an unauthorized access and documentation of inaccurate patient information or assessment in the patients' clinical records that could affect the patients quality of care and well-being. --- A review of Patient 1s ";Patient Face Sheet", indicated a start of care date (SOC) on 12/13/22, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/2023, at 12:15 p.m., with the Director of Nursing designee (DD), Patient 1s document titled, ";Certification of Terminal Illness (CTI, illness with a prognosis of having 6 months of life or less)", dated 12/13/22, in the section ";Hospice Physician Written Certification", an attestation confirming the narrative, indicated that it was composed by the doctor. The DD stated this section was written by the doctor and a signature would validate the narrative written. The DD also stated there was no signature on the document and there was no indication of who accessed the clinical record. During an interview on 10/13/23, at 12:40 p.m., The DD stated one of the nurses entered the information in the hospice physician narrative of the document and stated, she did not know who the nurse was, who documented the narrative. There was no indication of who accessed the clinical record. A review of Patient 1s document titled, ";Certification of Terminal Illness", dated 3/12/23, 6/10/23 and 8/9/23, indicated in the section ";Hospice Physician Written Certification" an attestation confirming the narrative was composed by the doctor. The document did not have the MD signature. There was no indication of who accessed the clinical record. There was no documented evidence the Patient 1s clinical record was safeguarded against unauthorized use. A review of Patient 2's ";Patient Face Sheet", indicated a start of care date (SOC) on 7/20/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/23, at 2:10 p.m. with the DD, Patient 2s document titled, ";Certification of Terminal Illness", dated 7/20/23. The record indicated in the section ";Hospice Physician Written Certification" an attestation confirming the narrative was composed by the doctor. The DD stated this section was written by the admitting nurse and stated the document was not signed by the doctor. There was no indication to show the admitting nurse had accessed and documented on the record. There was no documented evidence the Patient 2s clinical record was safeguarded against unauthorized use. A review of Patient 3's ";Patient Face Sheet", indicated a start of care date (SOC) on 9/18/23, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque/fat buildup in the wall of the arteries that supply blood to the heart). During a concurrent interview and record review on 10/13/23, at 2:20 p.m. with the DD, Patient 3s record titled, ";Certification of Terminal Illness (CTI)", dated 9/18/23, indicated in the section ";Hospice Physician Written Certification", an attestation confirming the narrative was composed by the doctor, the DD stated this section was written by the admitting nurse. The DD stated the document was not signed by the doctor. There was no indication to show the admitting nurse had accessed and documented on the record. There was no documented evidence the Patient 3s clinical record was safeguarded against unauthorized use. A review of Patient 4's ";Patient Face Sheet", indicated a start of care date (SOC) on 4/22/23, with a diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina (plaque/fat buildup in the wall of the arteries that supply blood to the heart). A record review of Patient 4s document titled, ";Certification of Terminal Illnes", dated 7/20/23, indicated a narrative was documented in the section titled ";Hospice Physician Written Certification". The document did not indicate who accessed the record to document the note. There was no documented evidence the Patient 4s clinical record was safeguarded against unauthorized use. A review of Patient 5's ";Patient Face Sheet", indicated a start of care date (SOC) on 9/27/23 with a diagnosis of hypertensive heart disease without heart failure (high blood pressure). A record review of Patient 5s document titled, ";Certification of Terminal Illness", dated 9/27/23, indicated a narrative was documented in the section titled, ";Hospice Physician Written Certification". The document did not indicate who accessed the record to document the note. There was no documented evidence the Patient 5s clinical record was safeguarded against unauthorized use. A review of Patient 6's ";Patient Face Sheet", indicated a start of care date (SOC) on 6/27/23 with a diagnosis of malignant neoplasm of bladder (cancer in the bladder). A record review of Patient 6s document titled, ";Certification of Terminal Illness", dated 6/27/23, indicated a narrative was documented in the section titled ";Hospice Physician Written Certification". The document did not indicate who accessed the record to document the note. There was no documented evidence the Patient 6s clinical record was safeguarded against unauthorized use. A review of Patient 7's ";Patient Face Sheet", indicated a start of care date (SOC) on 4/15/23 with a diagnosis of unspecified heart disease. A record review of Patient 7s document titled, ";Certification of Terminal Illness", dated 4/15/23, indicated a narrative was documented in the section titled, ";Hospice Physician Written Certification". The document did not indicate who accessed the record to document the note. There was no documented evidence the Patient 7s clinical record was safeguarded against unauthorized use. A review of the hospice agencys undated document titled, ";Job Description Medical Director", indicated, ";The Medical Director or physician designee reviews the clinical information for each Hospice patient and provides written certification that it is anticipated that the patients life expectancy is 6 months or less if the illness runs its normal course."

Upon patient record review, 1 of 5 (Patient #5) did not contain evidence that the Plan of Care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments. The 90-day Plan of Care dated 02/07/22, under the cardio section, ordered the intervention of, "Use compression stockings if available." This is not a specific/individualized Physician treatment order.

Upon patient record review, 1 of 5 (Patient #5) did not contain evidence that the IDG had ensured that all care and services were provided in accordance with the Plan of Care. The 90-day Plan of Care dated 02/07/22 listed, "Instruct patient/caregiver on passive Range of Motion exercises." There was no documented evidence in the record that this intervention had been followed through with.

Upon patient record review, 1 of 5 (Patient #2) did not contain evidence that if a drug order is verbal, or given via an electronic transmission, it is given to a Registered Nurse, Nurse Practitioner, Pharmacist, Physician or other licensed individual as designated by State regulations. The person receiving the order records and signs it immediately and has the prescribing person sign it in accordance with state and federal regulations. This patient's in-home caregiver contacted the Hospice the evening of 05/02/22, reporting the patient was 'shaking'. An LVN made a home visit, and identified a fever. The Physician was contacted, and an ATB and Tylenol for fever were ordered. This verbal order did not get transcribed into writing, nor forwarded to the ordering Physician for signature/date.