Every finding on record at Ed & Ar Hospice Care, Inc

Northridge, California · CCN 921595

20 findings across 2 surveys, in the inspector's own words.

The inspector’s own words from form CMS-2567, unedited, including CMS’s own spacing. Names and some dates are redacted by CMS.

Survey of October 10, 2023

15 findings

L0519

Based on interviews and record reviews, the hospice agency (HA, agency providing care to terminally ill [a disease or condition due to which a patient's death is anticipated] patients who have six months or less to live) failed to provide information about the hospice services and limitation of services in their own language for one out of 15 sampled patients (Patient 15). This deficient practice had the potential for misinformation, misunderstanding and miscommunication of hospice care and services provided for the patients. --- A review of Patient 15s Patient Information sheet indicated Patient 15 admission dated 8/9/2023 with diagnosis of hypertensive heart disease (refers to a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation) and diabetes (too much sugar in the blood). A review of Patient 15s ";Physician's Certification for Hospice Benefit" dated 8/9/2023 indicated, Patient 15 ambulate with walker with maximum assistance. The Notes indicated Patient 15's Performance Palliative Scale (PPS) of 50 percent, (spends the majority of the day sitting or lying down due to fatigue from advanced disease and requires considerable assistance to walk even for short distances but who is otherwise fully conscious level with good intake). During a joint home visit on 10/7/2023 at 10:00 a.m., with the Licensed Vocational Nurse 1 (LVN 1) was conducted at Patient 15's residence, Patient 15 was observed able to get out of her home and could go down the stairs and opened the house gate without assistance. Patient 15 was observed alert and oriented to name, place and time and able to verbalize needs through Spanish language. During the observation and a review at the same time at 10:00 a.m., of the patient hospice agency's handbook, the HA's handbook was written in the English language. During a concurrent interview with Patient 15 at the same date and time, Patient 15 stated she could understand English but is comfortable speaking , reading and writing in Spanish. Patient 15 stated that since admission , she was not able to read her patient's handbook. Patient 15 stated she called 5 different hospice agency's contact numbers but no one called her back. Patient 15 stated she called 911 instead and went to the emergency room (ER) due to not feeling well. During an interview with LVN 1 on 10/7/2023 at 11:00 a.m., LVN 1 stated it was better to have a patient handbook written in the patient's language to better understand the agency's services and to know who to call during an emergency. During an interview with the Intake Coordinator (IC) on 10/9/2023 at 10:30 a.m., IC stated she knew and spoken to Patient 15 and knows her personally. IC stated that she has a granddaughter who lives in the home that can assist. IC stated she did not know about the neighbor whom the patient enlisted as a primary caregiver. During an interview with the Assistant Administrator (AA) on 10/8/2023 at 12:30 p.m., AA stated that most of their patients were spanish speaking and is assigned to a spanish speaking visiting nurse. When asked if they also have a patient handbook that is translated in spanish, AA stated "No we don't have, but we can have it made." When asked about the emergency phone numbers, AA stated that she does not recall if she received the call or if the patient even left a message. AA stated that they would look into the matter further to prevent it from happening again. During an interview with the Director of Patient care services (DPCSD) on 10/10/2023 at 11:20 a.m., The DPCSD stated that there should be a continuous education for the patients about hospice services every nurse home visits. DPCSD stated that nurses and other field staff should educate and offer hospice services and explain what these hospice services are for as often as they should and document it o the electronic medical record. DPCSD also stated that a staff is usually assigned to a patient that that is able to speak with the same language. DPCSD stated she does not know whether they have a patient handbook that is available that is translated in their language. DPCSD also stated there should always be an on-call person who will answer the call in cases of emergency. A review of the HA's policy titled "Patient Education Process" revised 11/20 indicated that patients and family/caregivers will receive education in verbal, visual, and written format, as appropriate. The scope of teaching will be determined by the assessed needs, abilities, learning preferences, and readiness to learn of the patient and family/caregiver, as well as by the plan of care. A review of the HA's policy titled On Call/Weekend Services" revised 11/20 indicated that there will be on-call staff available after office hours, Monday through Friday, and 24 hours a day on weekends and holidays. Staff on call will be: 1. Administrative call by a senior management staff member2. Clinical call by a registered nurse3. Other interdisciplinary group members, as needed (e.g., social worker, Hospice Chaplain). On-call staff will respond to a page within 15 minutes and must be able to reach a patient within one (1) hour. (There may be rare exceptions, depending on how far away the patient lives and if the staff member is with another patient at the time of the page.) The on-call nurse will report his/her evening and/or weekend patient care activities to the Clinical Director on the next business day.

L0520

L0522

Based on interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to assess two of fifteen sampled patients (Patients 3 and 5) for hospice care and services by failing to: 1. Conduct an initial comprehensive assessment (an evaluation of the patient's physical, psychosocial [mental, social, and spiritual aspects], and emotional status related to the terminal illness [illness with a prognosis of having six months of life or less to live]) within 48 hours of admission in order to develop and implement an individualized plan of care to address the physical, emotional, and spiritual needs for Patients 3 and 5. 2. Ensure there was a full time Director of Patient Care Services (DPCS) to oversee the overall patient care, which included initial assessments were completed within 48 hours of admission. These deficient practices had the potential to cause delay of care and undetected signs of physical, emotional, and spiritual needs for Patient 3 and Patient 5. On 10/10/2023 at 12 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient) in the presence of the facilitys Administrator/Director of Patient Care Services (ADM/DPCS, the ADM and DPCS are the same person) due to facilitys failure to conduct the initial assessments for Patients 3 and 5 within 48 hours of admission. On 10/10/2023 at 2:15 p.m., the Department received the IJ Removal Plan (the facilitys plan of action to correct the deficient practices) from the agency by email, and the survey team notified on 10/10/2023 at 3:17 pm. the Director of Patient Care Services Designee (DD) the IJ Removal Plan was not accepted. On 10/10/2023 at 3:19 p.m., the survey team completed the survey tasks and exited with the IJ situation not removed. On 10/30/2023, the Administrator submitted an acceptable IJ removal plan that included the following: 1. Hospice Registered Nurse conducted an initial assessment for Patient 3 and Patient 5 on 10/10/2023 and completed documentation for initial assessment on 10/10/2023. In addition to reviewing Patient 3 and Patient 5, DPCS Designee reviewed all remaining 39 active patients initial assessments on 10/11/2023 for evidence of completion within 48 hours from admission. 38/39 Patients had completed RN initial assessments within 48 hours of admission. 1/39 Patient who did not have completed initial assessment as of the time of review, hospice registered nurse conducted an initial assessment on 10/11/2023. and completed documentation on 10/11/2023, 41/41 Patients have completed initial assessments by the end of day on 10/11/2023. DPCS Designee conducted an in-service on 10/12/2023, to educate hospice staff on guidelines to conducting and documenting an initial assessment within 48 hours. Registered Nurse Consultant from outside consulting firm conducted In-Service with appropriate hospice staff on IJ -System Failure In-Service: Guidelines for the comprehensive assessment and Documentation submission on 10/18/2023. All new admission will be audited by DPCS within 48hours of election to ensure that there is evidence of a completed initial assessment in the patient record.All new admission audited for at least 90 days. 2. New Full Time Director of Patient Care Services qualified in accordance with agencys policies and procedure is Hired to oversee the overall care of hospice patient with start date 10/16/2023.CEO will conduct performance evaluation within 30 days of hire to ensure DPCS is performing job duties in accordance with agencies policies and procedure. 3. IDG members including RN, Chaplain, Social Worker, and Medical Director held a meeting and updated Patient 3 and Patient 5 Care Plan on 10/10/2023. On 10/11/2023, IDG members held a meeting and updated care plan for patient who did not have initial assessment completed within 48 hours identified by DPCS Designee during review on 10/11/2023. Patient 3 and Patient 5 Care plan updated on 10/10/2023. Audit all patient records to ensure that there is evidence of completed updated plan of care no later than every 15 days. Audit will be done every 15 days by DPCS for at least 90 days. 4. Hospice Medical Director completed CTI for patient 5 on 10/10/2023.Audit all patient records to ensure that there is evidence of completed certification of terminal illness. Audit will be done every 15 days by DPCS for at least 90 days. On 10/30/2023 at 3:15 p.m., the survey team removed the IJ in the presence of the Director of Patient Care Services and the Licensed Vocational Nurse, after verifying and confirming onsite that the agency implemented the IJ removal plan. --- During a review of the facilitys form titled ";Application for Employment," dated 2/1/2020, the form indicated the ADM/DPCS signed the Application for Employment form. The form indicated the ADM/DPCS accepted a part time position at the HA. During a review of Patient 3s Personal Information, the Personal Information indicated Patient 3 had a Start of Care (SOC) of 9/15/2023 with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that damages the lungs in ways that make it hard to breathe) and chronic diastolic congestive heart failure (weak heart which causes fluid buildup). A telephone interview with Patient 3s Family Member 1 (FAM 1) was attempted on 10/7/2023, at 6:22 p.m., with no success. A telephone interview with Patient 3s FAM 2 was attempted on 10/7/2023, at 6:23 p.m., with no success. During a telephone interview on 10/8/2023, at 12:45 p.m., with the HAs Medical Director 1 (MD1), MD1 stated in general, she filled out the Certification for Terminal Illness (CTI, a certification signed by a physician after reviewing a patients clinical information to determine if hospice care criteria are met and/or provide an initial written certification that the patient had six months or less to live if the illness runs its normal course) at the start of care. MD 1 stated her signature on the CTI form indicated the patient (in general) had a medical condition of six months or less if the disease continued. MD1 stated she relied on the nurses initial comprehensive assessment of the patients (in general) and a face-to-face video interview to certify a patient (in general) for hospice services. MD1 stated she used the Local Coverage Determination (LCD, to provide guidance in determining medical necessity of services) guidelines as the primary tool to admit the patients. During a concurrent telephone interview and record review, on 10/8/2023, at 1:45 p.m., with MD 1, Patient 3s Physician Certification for Hospice Benefits CTI record, dated from 9/15/2023 to 12/13/2023, was reviewed. The Physician Certification for Hospice Benefits/CTI form indicated it was blank. MD1 stated the Physician Certification for Hospice Benefits/CTI form was not filled out, ";Its incomplete. It does not have my signature." MD1 stated the HA provided hospice care without certification. During a concurrent interview and record review, on 10/9/2023, at 4:11 p.m., with the DD, Patient 3s Comprehensive Nursing Assessment, dated 9/15/2023 was reviewed. The Comprehensive Nursing Assessment it was blank. The DD stated Patient 3s initial comprehensive assessment was not completed and stated the initial assessment needed to be done by 9/17/2023 to start Patient 3s Plan of Care (POC). DD stated Patient 3s POC was not completed, and the visiting nurses (unidentified) provided general nursing care without an individualized patient care. The DD stated Patient 3 did not receive individualized care based on Patient 3s needs. During a review of Patient 5s Personal Information, the Personal Information indicated Patient 5 had a SOC date of 9/25/2023 with diagnoses including cerebral infarction (disruption of blood flow to the brain) and unspecified dementia (loss of memory and other mental abilities severe enough to interfere with daily life). During an interview on 10/8/2023, at 10:35 a.m., with the DD, the DD stated, in general, the HA had 48 hours to complete a patients initial comprehensive assessment. The DD stated during the nurses initial assessment, the nurse would call MD 1 to discuss the case, develop and initiate the patients POC to address the patients needs. During a concurrent telephone interview and record review, on 10/8/2023, at 2:07 p.m., with MD1 of Patient 5s Comprehensive Nursing Assessment dated 9/25/2023, the assessment form indicated there was no documentation of an initial comprehensive assessment. MD 1 stated there was no initial comprehensive nursing assessment for Patient 5 and there was no a history and physical (H&P, a term used to describe a physician's examination of a patient) completed. MD1 stated without Patient 5s nursing comprehensive initial assessment or H&P, she (MD1) would not be able to answer any questions regarding Patient 5. MD 1 indicated there were no documented MD visits for Patient 5. MD1 stated she did not know if Patient 5 was eligible for hospice services. MD1 stated, ";I would make the assumption that he is, I dont know. I dont know how we ended up with him. I cant give you a lot of information on his case." During an interview on 10/9/2023, at 10:23 a.m., with the ADM/DPCS, the ADM/DPCS stated she would oversee the overall patient care. ADM/DPCS stated she would go to the HA once or twice a week. During an interview on 10/9/2023, at 10:55 a.m., with the ADM/DPCS, the ADM/DPCS stated she would end the interview because she had to go back to her other job at a hospital. During a telephone interview on 10/9/2023, at 11:10 a.m., with the HAs Owner (OW), the OW stated the ADM/DPCS was a part time employee. During a concurrent interview and record review, on 10/9/2023, at 4:16 p.m., with the DD, Patient 5s Comprehensive Nursing Assessment dated 9/25/2023 was reviewed. The Comprehensive Nursing Assessment form indicated; it was not completed. The DD stated Patient 5s initial nursing comprehensive assessment was not done, and the initial nursing comprehensive assessment needed to be completed within 48 hours of admission. The DD stated Patient 5 did not receive an individualized care based on Patient 5s needs. A record review of the HAs policy and procedure titled, ";Initial Assessment" revised November 2020, indicated ";An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care...Based on the initial assessment, the plan of care will be initiated on the day of admission." A record review of the HAs policy and procedure titled, ";Comprehensive Assessment," revised November 2020, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant – Specific, individualized patient needs/problems pertinent to the hospice care being provided." A record review of the HAs policy and procedure titled, ";The Plan of Care" revised November 2020, indicated ";A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care...The plan of care will be reviewed prior to care being delivered. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care." A review of facilitys policy & procedure titled ";Certificate of Terminal Illness" revised November 2020, indicated ";At the time of admission to hospice, the hospice Medical Director or the patients attending physician will complete a certification narrative that reflects the patients individual circumstances based on his/her review of the patients medical record or if applicable examination of the patient. The hospice Medical Director and the patients attending physician will sign the certification of terminal illness and authorization for hospice services forms."

L0523

Based on interview and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live). failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meet together to develop and complete a comprehensive and customized plan of care (POC – individualized care planned) within five (5) calendar days after admission to hospice care, for seven of 15 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). This deficient practice had the potential for in Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7 not receiving the individualized appropriate healthcare services that could affect their quality of life. --- A review of Patient 1s Personal Information indicated P1 had a Start of Care (SOC) date of 7/31/2023 with diagnoses including Alzheimers Disease (progressive disease of memory loss). A review of Patient 1's ";POC Summary" indicated ";Medical Social Worker initial assessment within 5 days of admission... Spiritual Counselor initial assessment within 5 days of admission." A review of P1 medical record form titled ";POC / IDG Review" dated 7/31/2023, indicated section ";RN Signature" was left blank. During a concurrent telephone interview and record review on 10/8/2023 at 1:12 p.m. with the MD1 of P1s Electronic Medical Record (EMR) medical record form titled ";POC/IDG Review" dated 7/31/2023, 9/14/2023, 8/3/2023, 8/17/2023, and 8/31/2023, MD1 stated that none were completed. During a concurrent interview and record review on 10/9/2023 at 10:23 a.m. with the Director of Patient Care Services (DPCS) of P1s EMR, the DPCS stated that she needs to be present in the IDG meetings because it was a part of her responsibilities. DPCS stated ";Its one thing we need to improve on." DPCS stated that the last time she attended an IDG meeting was in early September. DPCS stated that she does not document the meeting discussion in the medical record. DPCS stated that the discussion needs to be documented to update the patients plan of care, medications, activities, and any new orders. DPCS stated that the members signature in the IDG meeting indicated their attestation of being part of the IDG. A review of Patient 2s ";Personal Information" indicated Patient 2 had a SOC date of 5/10/2022 with diagnoses including Alzheimers Disease (progressive disease of memory loss). A review of Patient 2's ";POC / IDG Review" dated 5/10/2023, indicated sections ";RN Signature & Chaplain Signature" were left blank. During a concurrent telephone interview and record review on 10/8/2023 at 1:25 p.m. with the MD1 of P2s EMR, MD1 stated ";Things have fallen through the cracks for this patient." MD1 stated that she was unable to answer any other questions about P2 because she did not have a note documented for this patient. A review of Patient 3s ";Personal Information" indicated Patient 3 had a Start of Care (SOC) date of 9/15/2023 with diagnoses including chronic obstructive pulmonary disease (COPD – difficulty breathing) and chronic diastolic congestive heart failure (weak heart, which causes fluid buildup). A review Patient 3s ";POC/IDG Review" dated 9/15/2023, indicated sections ";IDG Discussion / Updated Comprehensive Assessment Review – Nursing, Level of Care, MD signature, RN signature, MSW signature, and Chaplain signature" were left blank. A review of Patient 4s ";Personal Information" indicated P4 had a SOC date of 10/20/2022 with diagnoses including heart disease. A review of P4 medical record form titled ";POC / IDG Review" dated 10/24/2022, indicated sections ";IDG Discussion / Updated Comprehensive Assessment Review – Nursing, Spiritual and Other Physician; Chaplain signature" were left blank. A review of Patient 5s ";Personal Information" indicated P5 had a SOC date of 9/25/2023 with diagnoses including cerebral infarction (disruption of blood flow to the brain). A review P5s EMR on 10/6/2023 at 3:57 p.m. P5s medical record form titled, ";POC/IDG Review" dated 9/25/2023, indicated sections ";RN signature, Chaplain signature, and MSW signature" were left blank. During a concurrent telephone interview and record review on 10/8/2023 at 2:07 p.m. with MD1 of P5s EMR, MD1 stated that she did not know anything about P5 yet. MD1 stated ";As of this time, I dont know if he is hospice eligible. I cant give you a lot of information about his case." MD1 stated that she was unable to provide any information due to the admitting nurse not documenting her admission assessment thus far. A review of Patient 6s ";Personal Information" indicated Patient 6 had a SOC date of 9/7/2022 and an End of Care (EOC) date of 8/31/2023, with diagnoses including heart failure (weak pumping of the heart). A review of Patient 6's ";POC / IDG Review" dated 9/7/2022, indicated section ";Chaplain Signature" was left blank. A review of Patient 7s ";Personal Information" indicated P7 had a SOC date of 4/1/2022 and an End of Care (EOC) date of 5/31/2023, with diagnoses including unspecified malignant neoplasm of skin (skin cancer). A review of P7 medical record form titled ";POC / IDG Review" dated 4/1/2023, indicated there were no discussion notes or signatures on form. During an interview on 10/8/2023 at 11:25 a.m. with the Director of Patient Care Services Designee (DD), DD stated that the IDG members, RN, MD, MSW, and SC must be present in the IDG meetings. DD stated that there is no RN assigned to attend the meetings, and that the DPCS is mainly the RN that attends. DD stated the IDG meetings are held every 14 days, and the last meeting was held on 9/28/2023. DD stated that the members signature on the forms indicate they attended the meeting. DD stated that the IDG form must be signed the day of the meeting. During an interview on 10/8/2023 at 11:26 a.m. with the Administrator Assistant (AA), the AA stated that all the employees have access to their EMR system, and that is where they need to sign because the HA has not had physical sign in sheets since 2020. During an interview on 10/8/2023 at 11:27 a.m. with the DD, DD stated that the IDG discussion sections for clinical, spiritual, medical social worker and another for anyone who attends the IDG, need to be filled out to know what was discussed. DD stated that based on the documentation in the discussion sections, the IDG will determine if the patient continues to qualify for hospice. During a telephone interview on 10/8/2023 at 12:45 p.m. with the MD1, MD1 stated that she is a member of the IDG and that they meet every two weeks. MD1 stated that she relies on the DON (Director of Nurses) to complete the documentation on the IDG. MD1 stated ";I havent done good documentation." A record review of facilitys record titled ";Job Description – Hospice Medical Director" revised November 2020, indicated ";The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group... Attending interdisciplinary group meetings and working in a team approach with the group." A record review of the HAs policy and procedure titled, ";The Plan of Care" revised November 2020, indicated ";A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care...The plan of care will be reviewed prior to care being delivered. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care." A record review of the HAs policy and procedure titled, ";Comprehensive Assessment" revised November 2020, indicated ";During the comprehensive patient assessment, all base line data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant: Specific, individualized patient needs/problems pertinent to the hospice care being provided." A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" revised November 2020, indicated ";The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care... Each patient plan of care will be updated utilizing the results from the ongoing comprehensive assessment... The hospice Medical Director and all hospice interdisciplinary group members will be present..."

L0524

Based on interview and record review the Hospice Agency (HA) failed to ensure the comprehensive assessment identified the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that addressed the hospice patient's well-being, comfort, and dignity throughout the dying process for two of 15 patients (Patient 4 and Patient 7). This deficient practice had the potential for he patients not receiving appropriate healthcare services that could affect their quality of life. --- A review of Patient 4s ";Personal Information" indicated Patient 4 had a Start of Care (SOC) date of 10/20/2022 with diagnoses including heart disease. A review of Patient 4's ";POC (Plan of Care) / IDG Review" dated 10/24/2022, indicated sections ";IDG Discussion / Updated Comprehensive Assessment Review – Nursing, Spiritual and Other Physician; Chaplain signature" were left blank. A review of Patient 7s ";Personal Information" indicated Patient 7 had a Start of Care (SOC) date of 4/1/2022 and an End of Care (EOC) date of 5/31/2023, with diagnoses including unspecified malignant neoplasm of skin (skin cancer). A review of Patient 7 ";POC / IDG Review" dated 4/1/2023, indicated there were no discussion notes or signatures on form. During an interview on 10/8/2023 at 11:25 a.m. with the Director of Patient Care Services Designee (DD), DD stated that the IDG members, RN (Registered Nurse), MD (Medical Director), MSW (Medical Social Worker, and SC (Spiritual Counselor), must be present in the IDG meetings. DD stated that there is no RN assigned to attend the meetings, and that the Director of Patient Care Services (DPCS) is mainly the RN that attends. DD stated the IDG meetings are held every 14 days, and the last meeting was held on 9/28/2023. DD stated that the members signature on the for indicate they attended the meeting. DD stated that the IDG form must be signed the day of the meeting. During an interview on 10/8/2023 at 11:26 a.m. with the Administrator Assistant (AA), the AA stated that all the employees have access to their EMR system, and that is where they need to sign because the HA has not had physical sign in sheets since 2020. During an interview on 10/8/2023 at 11:27 a.m. with the DD, DD stated that the IDG discussion sections for clinical, spiritual, medical social worker and another for anyone who attends the IDG, need to be filled out to know what was discussed. DD stated that based on the documentation in the discussion sections, the IDG will determine if the patient continues to qualify for hospice. During an interview on 10/8/2023 at 11:40 a.m. with the DD, DD stated, ";Patients need to be assessed so we can provide support. If we dont complete an assessment, we might be missing an important need that the patient needs." During a telephone interview on 10/8/2023 at 12:45 p.m. with the MD1, MD1 stated that she is a member of the IDG and that they meet every two weeks. MD1 stated that she relies on the DON (Director of Nurses) to complete the documentation on the IDG. MD1 stated ";I havent done good documentation." A record review of facilitys record titled ";Job Description – Hospice Medical Director" revised November 2020, indicated ";The hospice Medical Director will provide oversight of physician services by complementing attending physician care, acting as a medical resource to the interdisciplinary group... Attending interdisciplinary group meetings and working in a team approach with the group." A record review of the HAs policy and procedure titled, ";The Plan of Care" revised November 2020, indicated ";A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care...The plan of care will be reviewed prior to care being delivered. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care." A record review of the HAs policy and procedure titled, ";Comprehensive Assessment" revised November 2020, indicated ";During the comprehensive patient assessment, all base line data and other relevant information will be documented in the patients clinical record, including at least the following information, as relevant: Specific, individualized patient needs/problems pertinent to the hospice care being provided." A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" revised November 2020, indicated ";The interdisciplinary group will meet on a regular basis to discuss patient and family/caregiver changes and progress and updates to the plan of care... Each patient plan of care will be updated utilizing the results from the ongoing comprehensive assessment... The hospice Medical Director and all hospice interdisciplinary group members will be present..."

L0530

Based on observation, interview and record review, the Hospice Agency (HA) staff failed to review all medications the patient was taking and update the medication profile with the currently used medications for one of 15 sampled patients (Patient 15). This deficient practice had the potential to put the patient at risk for medication errors, side effect, and adverse drug reactions. --- A review of Patient 1s (P1) medical record form titled ";Personal Information" indicated P1 had a Start of Care (SOC) date of 7/31/2023 with diagnoses including Alzheimers Disease (progressive memory loss). A review of P1s medical record form titled ";Current Treatment / Medication / DME List" indicated ";Valproic Acid 500mg (milligrams)/10ml (milliliters) solution - 10 ml by mouth twice a day – agitation." During a join home visit on 10/7/2023 at 11:15 a.m. with the Administrator Assistant (AA) at P1s home, AA stated that when she reconciles patients medications she checks dosage, expiration, frequency, and how the care giver is following the order. AA reconciled P1s medication with the HAs medication profile documented for P1. After P1s medications were reconciled by AA, AA was asked if she check all the expirations dates on the bottles. AA stated, ";I didnt check that today, but I do." AA was made aware that P1s Valproic Acid medication label had an expiration date of 9/12/23. AA stated, ";Its expired, I didnt catch that." AA stated, ";when its expired, we need to reorder it. We can harm the patient. I know what medication loses its effectiveness if its expired." During an interview on 10/8/2023 at 11:37 a.m. with the Director of Patient Care Services Designee (DD), DD stated that patients medication profile needs to be reconciliated at every nursing visit. DD stated that medication reconciliation includes looking at the medication name, dosage, frequency, route, and expiration date. DD stated that a patient might die if they take a medication that is not needed. DD stated, ";It harms the patient." A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" revised November 2020, indicated ";An interdisciplinary group meeting plan of care update form will be used... It will note changes, responses to treatment and progress toward outcomes, which may include: plan for changes in treatments or procedures." A record review of the HAs policy and procedure titled, ";Comprehensive Assessment" revised November 2020, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented...including at least... review of current and related past medications..." A record review of the HAs policy and procedure titled, ";Medication Profile" revised November 2020, indicated ";Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. A comparison of the medications ordered for the patient while under the organizations care will be made to those on the list. Visiting personnel will do medication reconciliation on every visit." b. A review of Patient 15s face sheet indicated an admission date of 8/9/23 with the medical diagnosis of hypertensive heart disease (refers to a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation) and diabetes (too much sugar in the blood). A review of Patient 15s ";Physician's Certification for Hospice Benefit" dated 8/9/23 indicated that Patient 15 is able to ambulate with walker with maximum assistance. PPS of 50 percent ( Performance Palliative Scale- spends the majority of the day sitting or lying down due to fatigue from advanced disease and requires considerable assistance to walk even for short distances but who is otherwise fully conscious level with good intake). On 10/7/23 at 10:00 a.m., a joint home visit with the Licensed Vocational Nurse 1 (LVN 1) was conducted at Patient 15's residence. Observed that Patient 15 was able to get out of her home, able to go down the stairs and open her gate without any assistance. Patient 15 is alert and oriented to name, place and time. Able to verbalize needs. Complained of 4/10 mouth pain. During the observation and concurrent review of medications with LVN 1 at the same date at 11:00 a.m., noticed that the Patient 15's medication bottles were old and some had no labels on them. On concurrent interview with Patient 15, stated when she receives her new medications, she transfers them to the bottles inside her small bag and throws the new bottles in the trash. There were no other bottles found in the home. Medication discrepancies were as follows: Metformin 1000 milligrams (mg- unit of measurement) 1 tablet twice daily was in a bottle without any labels on it.Glipizide 10 mg 1 tablet twice daily. Patient 15 stated it was increased to 25 mg twice daily was found inside an old bottle with faded label. Carbidoba-levidopa 25/100 mg 1 tablet three times a day for parkinson's was not listed on the medication profile. patient 15 stated it was prescribed by her neurologist last 6/2/23 with the current label.Tylenol 500 mg extra strength 2 tablets every 6 hours as needed for pain. Patient 15 stated not taking anymore.Meloxicam 7.5 mg 1 tablet once daily as needed for arthritic pain. Patient 15 denied taking anymore.Omeprazole 20 mg once daily for acid reflux. Patient stated she does not have the bottle. Lyrica 25 mg 1 to 3 tablets daily for nerve pain. Patient 15 stated she does not have at home. Percocet 10/325 mg 1 tablet every 6 hours as needed for severe pain. Patient 15 stated she does not take it anymore.Vitamin A and D ointment to right buttocks as needed for skin maintenance was not found in the home. Remedy Phytoplex Z-guard skin protectant paste apply to buttocks as needed for skin maintenance was not found in the home. During an interview with LVN 1 stated that updates in the medication profile should be updated every nurse home visit and should be reported to the doctor and the hospice agency for any changes. During an interview with the Director of Patient Care Services Designee (DPCSD) on 10/8/23 at 11:20 a.m., stated that the visiting nurse should compare and update the medications with the medications at the patient's home and the medication profile every home visit. A review of the HA's policy titled ' Medication Management" revised 11/2020, indicated a drug regimen review will be performed at the time of initial and comprehensive assessment. The review will assist in evaluating effectiveness and appropriateness, identify potential and actual drug/food interactions, adverse reactions, duplicative therapy and noncompliance issues, omissions and unclear information. During subsequent hospice visits, the medication profile will be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. This includes, but will not be limited to:A. Using the medication profile to evaluate the use of the drugs in the home settingB. Using the medication profile to teach drug purposes, dosages, routes, times, side effects, and contraindicationsC. Using the medication profile as a communication tool for other clinicians involved in care. Review of the medication profile, as well as other relevant data including the patient's age, sex, diagnoses, comorbidities, lab values, height, weight, allergies, and sensitivities will be considered when changing the plan of care.

L0531

Based on interview and record review the facility failed to conduct an initial bereavement (a services to help in grieving process through the first 13 months after the death) assessment to provide bereavement counseling in accordance with the patient/family's needs for two of 15 sample selected patients (Patient 3 and Patient 5). This deficient practice had the potential for the patient/family not being provided social, spiritual, and cultural support related to the patient's death. --- A review of Patient 3s ";Personal Information" indicated Patient 3 had a Start of Care (SOC) date of 9/15/2023 with diagnoses including chronic obstructive pulmonary disease (COPD – difficulty breathing) and chronic diastolic congestive heart failure (weak heart, which causes fluid buildup). A review Patient 3s ";POC (Plan of Care – an individualized plan that maps out needs and services supplied for a Medicare patient facing a terminal illness, as well as the patients family/caregiver) Summary" indicated ";Medical Social Worker initial assessment within 5 days of admission." It also stated, ";Bereavement Coordinator to assess and evaluate bereavement and grieving risk factors within 5 days of admission." A review Patient 3s medical record form titled, ";POC/IDG Review" dated 9/15/2023, indicated sections ";IDG Discussion / Updated Comprehensive Assessment Review – Nursing, Level of Care, MD signature, RN (Registered Nurse) signature, MSW (Medical Social Worker) signature, and Chaplain signature" were left blank. A review of Patient 3s ";History of Bereavement Assessment" under section ";Bereavement" indicated there were no assessment made, to indicate the services offered by the hospice agency, to identify the needs of the patient and or patient family. A review of Patient 5s ";Personal Information" indicated Patient 5 had a SOC date of 9/25/2023 with diagnoses including cerebral infarction (disruption of blood flow to the brain). A review Patient 5s ";POC Summary" indicated ";Medical Social Worker initial assessment within 5 days of admission." ";Bereavement Coordinator to assess and evaluate bereavement and grieving risk factors within 5 days of admission." A review Patient 5s ";POC/IDG Review" dated 9/25/2023, indicated sections ";RN signature, Chaplain signature, and MSW signature" were left blank. A review of Patient 5s ";History of Bereavement Assessment" under section ";Bereavement" indicated there were no progress notes made. During a concurrent telephone interview and record review on 10/8/2023 at 2:07 p.m. with the Medical Director 1(MD 1), MD1 stated, she did not know about Patient 5 yet. MD1 stated ";As of this time, I dont know if he is hospice eligible. I cant give you a lot of information about his case." During an interview on 10/8/2023 at 11:40 a.m. with the Director of Patient Care Services Designee (DD), DD stated the Spiritual Counselor (SC) or the Medical Social Worker (MSW) were responsible for the completion of patients initial bereavement assessment. DD stated that the patients need to be assessed, so that the HA can provide support. DD stated, ";If we dont complete an assessment, we might be missing an important need that the patient needs." On 10/8/2023 at 4:38 p.m. the HAs MSW was called, with no answer. Message with call back number left. During a telephone interview on 10/8/2023 at 4:52 p.m. with the Spiritual Counselor (SC), SC stated that Chaplain responsibilities included reviewing patient files, calling families to schedule a visit, and to identify spiritual needs. A record review of the HAs policy and procedure titled, ";Bereavement Assessment" revised November 2020, indicated ";On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment... the Bereavement Coordinator will review the bereavement risk assessment to determine potential needs of the survivors." A record review of the HAs policy and procedure titled, ";Bereavement Services" revised November 2020, indicated ";The program will provide bereavement services to the family/caregivers of hospice patients, before and after the patient death, in accordance with the plan of care. A Bereavement assessment will be completed by the hospice social worker at the time of admission to hospice. A record review of the HAs policy and procedure titled, ";Comprehensive Assessment" revised November 2020, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented...including at least... A bereavement assessment..."

L0533

Based on observation, interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the 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 and updated the comprehensive assessment at least every 15 days for seven of 15 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, and Patient 7). This deficient practice had potential for patients not to received care and services needed from reaching their goals. --- A review of Patient 1s ";Personal Information" indicated P1 had a Start of Care (SOC) date of 7/31/2023 with diagnoses including Alzheimers Disease (progressive disease of memory loss). A review of Patient 1's ";Plan of Care (POC ) Summary" indicated ";Interdisciplinary Team (IDT) to review every 2 weeks and as needed for change of condition. Medical Social Worker to evaluate and identify psychological and emotional need for patient and family during re-certification." A review of Patient 1's ";POC / IDG Review" dated 9/14/2023, 8/3/2023, 8/17/2023, and 8/31/2023, indicated there were not completed. During a concurrent telephone interview and record review on 10/8/2023 at 1:12 p.m. with the Medical Director 1 (MD1) of P1s Electronic Medical Record (EMR) medical record form titled ";POC/IDG Review" dated 7/31/2023, 9/14/2023, 8/3/2023, 8/17/2023, and 8/31/2023, MD1 stated that none were completed. During a concurrent interview and record review on 10/9/2023 at 10:23 a.m. with the Director of Patient Care Services (DPCS) of P1s EMR, the DPCS stated that she needs to be present in the IDG meetings because it was a part of her responsibilities. DPCS stated ";Its one thing we need to improve on." DPCS stated that the last time she attended an IDG meeting was in early September. DPCS stated that she does not document the meeting discussion in the medical record. DPCS stated that the discussion needs to be documented to update the patients plan of care, medications, activities, and any new orders. DPCS stated that the members signature in the IDG meeting indicated their attestation of being part of the IDG. A review of Patient 2s ";Personal Information" indicated P2 had a SOC date of 5/10/2022 with diagnoses including Alzheimers Disease (progressive memory loss). A review of Patient 2's ";POC Summary" indicated ";IDT to review every 2 weeks and as needed for change of condition. Medical Social Worker to evaluate and identify psychological and emotional need for patient and family during monthly visits and re-certification." A review of Patient 2s ";History of POC / IDG" under section ";IDG" indicated the last POC/IDG was documented on 8/15/2022. During a concurrent telephone interview and record review on 10/8/2023 at 1:25 p.m. with the MD1 of P2s EMR medical record form titled ";POC/IDG Review" MD1 stated that the last documented IDG/POC was on 8/15/22. A review of Patient 3s ";Personal Information" indicated Patient 3 had a SOC date of 9/15/2023 with diagnoses including chronic obstructive pulmonary disease (COPD, difficulty breathing) and chronic diastolic congestive heart failure (weak heart, which causes fluid buildup). A review of Patient 3's ";POC Summary" indicated ";IDT to review every 2 weeks and as needed for change of condition." A review of Patient 3's ";POC / IDG Review" dated 9/15/2023 and 9/28/2023, indicated there were not completed. A review of Patient 4s ";Personal Information" indicated Patient 4 had a SOC date of 10/20/2022 with diagnoses including heart disease. A review of Patient 4 ";POC Summary" indicated ";IDT to review every 2 weeks and as needed for change of condition. Medical Social Worker to evaluate and identify psychological and emotional need for patient and family during re-certification." A review of Patient 4's ";POC / IDG Review" dated 9/14/2023, 9/28/2023, 8/3/2023, 8/17/2023, and 8/31/2023, indicated there were not completed. A review of Patient 5s ";Personal Information" indicated Patient 5 had a SOC date of 9/25/2023 with diagnoses including cerebral infarction (disruption of blood flow to the brain). A review of Patient 5's ";POC Summary" indicated ";IDT to review every 2 weeks and as needed for change of condition." A review of Patient 5's ";POC / IDG Review" dated 9/25/2023 and 9/28/2023 indicated there were not completed. A review of Patient 6s ";Personal Information" indicated Patient 6 had a SOC date of 9/7/2022 and an End of Care (EOC) date of 8/31/2023, with diagnoses including heart failure (weak pumping of the heart). A review of Patient 6's ";POC Summary" indicated ";IDT to review every 2 weeks and as needed for change of condition. Medical Social Worker to evaluate and identify psychological and emotional need for patient and family during monthly visits and re-certification." A review of Patient 6 ";POC / IDG Review" dated 9/14/2023, 9/28/2023, 8/3/2023, 8/17/2023, and 8/31/2023, indicated there were not completed. A review of Patient 7s ";Personal Information" indicated Patient 7 had a SOC date of 4/1/2022 and an End of Care (EOC) date of 5/31/2023, with diagnoses including unspecified malignant neoplasm of skin (skin cancer). A review of Patient 7's ";POC Summary" indicated ";IDT to review every 2 weeks and as needed for change of condition. Medical Social Worker to evaluate and identify psychological and emotional need for patient and family during re-certification." A review of Patient 7's ";POC / IDG Review" dated 5/25/2023, 5/11/2023, 5/4/2023, and 4/20/2023 indicated there were not completed. During an interview on 10/8/2023 at 11:25 a.m. with the Director of Patient Care Services Designee (DD), DD stated that the IDG members, RN, MD, MSW, and SC must be present in the IDG meetings. DD stated that there is no RN assigned to attend the meetings, and that the DPCS is mainly the RN that attends. DD stated the IDG meetings are held every 14 days, and the last meeting was held on 9/28/2023. DD stated that the members signature on the for indicate they attended the meeting. DD stated that the IDG form must be signed the day of the meeting. During a telephone interview on 10/8/2023 at 12:45 p.m. with the MD1, MD1 stated that she is a member of the IDG and that they meet every two weeks. MD1 stated that she relies on the DON (Director of Nurses) to complete the documentation on the IDG. MD1 stated ";I havent done good documentation." During an interview on 10/8/2023 at 11:40 a.m. with the DD, DD stated, ";Patients need to be assessed so we can provide support. If we dont complete an assessment, we might be missing an important need that the patient needs." A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" revised November 2020, indicated ";A plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment." A record review of the HAs policy and procedure titled, ";Comprehensive Assessment" revised November 2020, indicated ";The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days." A record review of the HAs policy and procedure titled, ";The Plan of Care" revised November 2020, indicated ";The written plan of care will contain, but will not be limited to, the following: frequency of services... interdisciplinary group assessment of needs..." A record review of the HAs policy and procedure titled, ";Admission Criteria and Process" revised November 2020, indicated ";The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determinations (LCDs). Eligibility criteria will be continually reviewed by the interdisciplinary team to ensure appropriateness of hospice care."

L0536

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that healthcare organizations must meet in order to begin and continue participating in the Medicare [federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] and Medicaid [joint federal and state program that helps cover medical costs for some people with limited income and resources] programs) regarding care planning and coordination of services for patients was met as follows. --- 1. The HA failed to designate a Registered Nurse (RN) to coordinate and attend Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meetings to discuss patients plan of care, assessment of patient individualized care and needs of patients and patients family, for ten out of 15 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 9, Patient 10, and Patient 12). (Refer to L540). 2. The HA failed to ensure the IDG included the extent and frequency of specific care and services provided for two out of 15 sampled patients (Patient 3 and Patient 5). (Refer to L547). The cumulative effect of these systemic practices resulted in the failure of the HA to deliver statutorily mandated compliance with Federal regulations for Interdisciplinary group, care planning, and coordination of services.

L0540

Based on interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to designate a Registered Nurse (RN) to coordinate and attend interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting to discuss patients plan of care and assessment of patient individualized care and needs of patients and patients family for ten of 15 sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 9, Patient 10 and Patient 12). This deficient practice had a potential for delayed care and services to meet patients care goals for Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 9, Patient 10 and Patient 12. --- A review of Patient 1s (P1) medical record form titled ";Personal Information" indicated P1 had a Start of Care (SOC) date of 7/31/2023 with diagnoses including Alzheimers Disease (progressive memory loss). A review of P1 medical record form titled ";POC / IDG Review" dated 9/14/2023, 8/3/2023, 8/17/2023, and 8/31/2023, indicated there were not completed. During a concurrent telephone interview and record review on 10/8/2023 at 1:12 p.m. with the Medical Director 1 (MD1) of P1s Electronic Medical Record (EMR) medical record form titled ";POC/IDG Review" dated 7/31/2023, 9/14/2023, 8/3/2023, 8/17/2023, and 8/31/2023, MD1 stated that none were completed. A review of Patient 2s (P2) medical record form titled ";Personal Information" indicated P2 had a SOC date of 5/10/2022 with diagnoses including Alzheimers Disease (progressive memory loss). A review of P2s Electronic Medical Record (EMR) medical record form titled ";History of POC / IDG" under section ";IDG" indicated the last POC/IDG was documented on 8/15/2022. During a concurrent telephone interview and record review on 10/8/2023 at 1:25 p.m. with the MD1 of P2s EMR medical record form titled ";POC/IDG Review" MD1 stated that the last documented IDG/POC was on 8/15/22. A review of Patient 3s (P3) medical record form titled ";Personal Information" indicated P3 had a Start of Care (SOC) date of 9/15/2023 with diagnoses including chronic obstructive pulmonary disease (COPD – difficulty breathing) and chronic diastolic congestive heart failure (weak heart, which causes fluid buildup). A review of P3 medical record form titled ";POC / IDG Review" dated 9/15/2023 and 9/28/2023, indicated there were not completed. A review of Patient 4s (P4) medical record form titled ";Personal Information" indicated P4 had a Start of Care (SOC) date of 10/20/2022 with diagnoses including heart disease. A review of P4 medical record form titled ";POC / IDG Review" dated 9/14/2023, 9/28/2023, 8/3/2023, 8/17/2023, and 8/31/2023, indicated there were not completed. A review of Patient 5s (P5) medical record form titled ";Personal Information" indicated P5 had a Start of Care (SOC) date of 9/25/2023 with diagnoses including cerebral infarction (disruption of blood flow to the brain). A review of P5 medical record form titled ";POC / IDG Review" dated 9/25/2023 and 9/28/2023 indicated there were not completed. A review of Patient 6s (P6) medical record form titled ";Personal Information" indicated P6 had a Start of Care (SOC) date of 9/7/2022 and an End of Care (EOC) date of 8/31/2023, with diagnoses including heart failure (weak pumping of the heart). A review of P6 medical record form titled ";POC / IDG Review" dated 9/14/2023, 9/28/2023, 8/3/2023, 8/17/2023, and 8/31/2023, indicated there were not completed. A review of Patient 7s (P7) medical record form titled ";Personal Information" indicated P7 had a Start of Care (SOC) date of 4/1/2022 and an End of Care (EOC) date of 5/31/2023, with diagnoses including unspecified malignant neoplasm of skin (skin cancer). A review of P7 medical record form titled ";POC / IDG Review" dated 5/25/2023, 5/11/2023, 5/4/2023, and 4/20/2023 indicated there were not completed. During an interview on 10/8/2023 at 11:25 a.m. with the Director of Patient Care Services Designee (DD), DD stated that the IDG members, RN, MD, MSW, and SC must be present in the IDG meetings. DD stated that there is no RN assigned to attend the meetings, and that the DPCS is mainly the RN that attends. DD stated the IDG meetings are held every 14 days, and the last meeting was held on 9/28/2023. DD stated that the members signature on the for indicate they attended the meeting. DD stated that the IDG form must be signed the day of the meeting. During an interview on 10/8/2023 at 11:27 a.m. with the DD, DD stated that the IDG discussion sections for clinical, spiritual, medical social worker and another for anyone who attends the IDG, need to be filled out to know what was discussed. DD stated that based on the documentation in the discussion sections, the IDG will determine if the patient continues to qualify for hospice. During an interview on 10/8/2023 at 4:50 p.m. with the DD, DD stated that there is no specific RN assigned to attend the IDG meetings. DD stated that it was the responsibility of the DPCS to cover if an RN is not available to participate in the IDG meetings. During an interview on 10/9/2023 at 10:23 a.m. with the Director of Patient Care Services (DPCS), the DPCS stated that she needs to be present in the IDG meetings because it was a part of her responsibilities. DPCS stated ";Its one thing we need to improve on." DPCS stated that the last time she attended an IDG meeting was in early September. DPCS stated that she does not document the meeting discussion in the medical record. DPCS stated that the discussion needs to be documented to update the patients plan of care, medications, activities, and any new orders. DPCS stated that the members signature in the IDG meeting indicated their attestation of being part of the IDG. During a telephone interview on 10/8/2023 at 12:45 p.m. with the MD1, MD1 stated that she is a member of the IDG and that they meet every two weeks. MD1 stated that she relies on the DON (Director of Nurses) to complete the documentation on the IDG. MD1 stated ";I havent done good documentation." A record review of facilitys form titled ";Job Description – Clinical Director/Director of Patient Care Services" revised November 2020, indicated ";Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel." A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" revised November 2020, indicated ";A plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment." A record review of the HAs policy and procedure titled, ";Comprehensive Assessment" revised November 2020, indicated ";The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days." d. A review of Patient 9s (P9) medical record form titled ";Personal Information" indicated P9 had a SOC date of 5/9/23 with the medical diagnosis of malignant neoplasm of the skin ( skin cancer). A record review of P9s Electronic Medical Record (EMR) on 10/6/2023 at 7:30 p.m. medical record form titled ";Physician Certification for Hospice Benefit" indicated Certificate #7: 5/9/2023 to 8/7/2023 and Certificate #8: 8/7/2023 to 11/4/2023, ";Physician Narrative – Face to Face Summary, was left blank. It also indicated form was not signed by MD1. A record review of the electronic medical record "Audit log" on 10/8/23 showed that the physician just signed the document on 10/6/2023 at 2:25 p.m. e. A review of Patient 10s (P10) medical record form titled ";Personal Information" indicated P10 had a SOC date of 1/14/23 with the medical diagnosis of Alzheimer's disease. A record review of P10s Electronic Medical Record (EMR) on 10/6/2023 at 6:01 p.m., medical record form titled ";Physician Certification for Hospice Benefit" indicated Certificate #10: 7/11/23 to 9/11/23 and Certificate #11: 9/11/23 to 11/9/23, ";Physician Narrative – Face to Face Summary, was left blank. It also indicated form was not signed by MD1. f. A review of Patient 12s (P12) medical record form titled ";Personal Information" indicated P12 had a SOC date of 7/6/23 with the medical diagnosis of chronic right heart failure (the right side of the heart has lost its ability to pump. That means your heart can't fill with enough blood, and the blood backs up into the veins. If this happens, your legs, ankles, and belly often swell). A record review of P12s Electronic Medical Record (EMR) on 10/6/2023 at 5:32 p.m. medical record form titled ";Physician Certification for Hospice Benefit" indicated Certificate #3: 10/4/23 to 12/2/23, ";Physician Narrative – Face to Face Summary, was left blank. It also indicated form was not signed by MD1. A record review of the electronic medical record "Audit log" on 10/8/23 showed that the physician last signed the certification of MD last 8/8 23 at 4:26 p.m. During an interview with the DPCSD on 10/8/23 at 10:35 a.m., stated that the MD should complete the recertification for terminal illness and sign it within 48 hours on the electronic medical record. During an interview with the Medical Director (MD) on 10/9/23 at 12:15 p.m. MD stated that she is falling short in documentation and that she copies and paste the nurses assessments on the certification of terminal illness and sometimes amends it. A review of the HA's policy titled " Entries in the Clinical Record" revised 11/2020 indicated the plan of care will be provided to both the attending physician and the hospice Medical Director for approval of verbal orders and certification of the terminal illness signatures. The hospice Medical Director will need to review the patient's history and physical, which is also provided, to be able to sign the certification of terminal illness section of the plan of care. Entries into the clinical record will be made on the day care is provided to the patient. All documentation will be turned in to the office at the end of the workday.Signature authorization of clinical documentation will include the staff member's name and credentials (as specified on professional licenses and/or certification documents).

L0547

Based on interview, and record review, the hospice agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) included the extent and frequency of specific care and services provided for two out of 15 sample patients (Patient 3 and Patient 5). This deficient practice had the potential to result in not identifying the patient care and services needs and patients/care givers not being aware of the disciplines and the frequency of the visit from the agency. --- A review of Patient 3s Personal Information indicated Patient 3 had a Start of Care (SOC) date of 9/15/2023 with diagnoses including chronic obstructive pulmonary disease (COPD, a disease that damages the lungs in ways that make it hard to breathe) and chronic diastolic congestive heart failure (weak heart, which causes fluid buildup). A review Patient 3s Plan of Care (POC, an individualized plan that maps out needs and services supplied for a Medicare [a federal health insurance for people 65 or older, and some people under 65 with certain disabilities or conditions] patient facing a terminal illness [a disease or condition due to which a patient's death is anticipated in six months] as well as the patients family/caregiver) Summary indicated, under section ";Other - Medical Director 1 (MD1) to visit patient and sign patient correspondences while under (HA) care" and ";Skilled Nurse visit 1x (times) a week +3 PRN (as needed)". Section ";Frequency of Visits – HA 2 per week – to assist with ADLs." A review of Patient 3's POC/IDG Review dated 9/28/2023, indicated ";Frequency of visit: HA 2 per week – to assist with ADLs." During a concurrent interview and record review on 10/9/2023 at 4:11 p.m., of Patient 3s Comprehensive Nursing Assessment dated 9/15/2023, with the Director of Patient Care Services Designee (DD), DD stated that the Patient 3's Comprehensive Nursing Assessment assessment was incomplete and has no frequency of the visit. DD stated the Comprehensive Nursing Assessment should have been completed by 9/17/2023 with information on P3s visit frequencies. A review of Patient 5s Personal Information indicated, Patient 5 had a Start of Care (SOC) date of 9/25/2023 with diagnosis including cerebral infarction (disruption of blood flow to the brain). A review Patient 5s POC Summary indicated, under section ";Other - MD1 to visit patient and sign patient correspondences while under (HA) care" and ";Skilled Nurse visit 1x (times) a week +3 PRN (as needed)". Section ";Frequency of Visits – HA 3 per week – to assist with ADLs." A review of Patient 5's POC / IDG Review dated 9/25/2023, indicated ";Frequency of visit: HA 3 per week – to assist with ADLs." During an interview on 10/8/2023 at 10:35 a.m. with DD, DD stated, the admission assessment starts when the nurse visits the patients. DD stated that ";The initiation of POC starts that day." DD stated that the visit frequency is also discussed and established that day. A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" revised November 2020, indicated ";Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires." A record review of the HAs policy and procedure titled, ";Initial Assessment" revised November 2020, indicated ";Based on the initial assessments, the plan of care will be initiated on the day of admission." A record review of the HAs policy and procedure titled, ";The Plan of Care" revised November 2020, indicated ";A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care...The plan of care will be reviewed prior to care being delivered."

L0596

Based on interview and record review the Hospice Agency (HA) failed to ensure families had bereavement (the period of sorrow that follows the death of a loved one) counseling postmortem (the examination of a body after death) for one of 14 sampled patients (Patient 7). This failure resulted in families/care givers did not receive the bereavement services after their family member passed away. --- A review of Patient 7s Personal Information indicated Patient 7 had a Start of Care (SOC) date of 4/1/2022 and an End of Care (EOC) date of 5/31/2023, with diagnoses including unspecified malignant neoplasm of skin (skin cancer). A review on 10/6/2023 at 4:24 p.m. of Patient 7s ";History of Bereavement Letter" under section ";Bereavement" indicated there was nothing documented. A review on 10/6/2023 at 4:25 p.m. of Patient 7s post-Death Bereavement Support" under section ";Bereavement" indicated there was nothing documented. It also indicated a under section ";Bereavement Letter – 6/30/23-overdue 8/31/23-overdue". During an interview on 10/8/2023 at 11:47 p.m. with the Director of Nurses Designee (DD), the DD stated that when a patient expires, the bereavement coordinator needs to do the post bereavement assessment to assess the familys need and offer assistance if needed. DD stated that, depending in the assessment the facility sends bereavement letters postmortem at three, four, six, nine, and twelve-months intervals. A record review of the HAs policy and procedure titled, ";Bereavement Services" revised November 2020, indicated ";(HA) will provide an organized bereavement program supervised by a qualified Bereavement Coordinator for up to one year following the death of the patent. The program will provide bereavement services to the family/caregivers of hospice patients, before and after the patient death, in accordance with the plan of care. A Bereavement assessment will be completed by the hospice social worker at the time of admission to hospice.

L0664

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Medical Director was met as follows: --- 1. The HA failed to ensure the Medical Director and/or the physician designee a hospice employee or under the contract with the hospice) had a responsibility for the medical component of the hospices patient care program, review, and verify the patient overall health information necessary for initial certifications, to support diagnosis of the patients terminal illnesses and to qualify for hospice benefits for six out of 15 sampled patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 6 and Patient 7). (Refer to L 667). 2. The hospice agency failed to ensure medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for three of 15 sample patients (Patient 2, Patient 4, and Patient 6). (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.

L0667

Based on an interview and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure, the medical director and/or physician designee had a responsibility for medical component of hospice's patient care program, review, and verify the patient overall health information necessary for initial certifications, to support diagnosis of the patients terminal illnesses and to qualify for hospice benefits for six out of 15 sampled patients (Patient 2, Patient 3, Patient 4, Patient 5, Patient 6 and Patient 7) This deficient practice resulted in the hospice medical director and/or the hospice attending physicians certified the patients for hospice care and services without documentation of clinical evidence to support the terminal illness diagnoses and had a potential for the patients not receiving appropriate healthcare services that could affect their quality of life. --- A review of Patient 2s Personal Information indicated Patient 2 had a Start of Care (SOC) date of 5/10/2022 with diagnosis including Alzheimers Disease (progressive memory loss). A review of Patient 2s Physician Certification for Hospice Benefit under section ";Physician - CTI" Certificate number one dated 5/10/2022 to 8/7/2022, indicated the Medical Director (MD1) names was documented on the form. The Physician Certification for Hospice Benefit indicated the License Vocational Nurse 1 (LVN1) electronically documented ";Signature on file verified by (LVN1) on 5/10/2022 and indicated ";I attest/confirm I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". During a telephone interview on 10/7/2023 at 12:45 p.m. with the Medical Director 1 (MD1), MD1 stated she provides medical oversite. MD1 stated, ";Primary is to be a medical consultant of day-to-day issues that arrive." MD1 stated before a patient would be admitted to hospice care and services, the hospice staff (in general) would screen the patient to see if appropriate for hospice. MD1 stated that for the patient with a community referral, she relied on the interview and the nurses examination. MD1 stated that she uses the LCD (Local Coverage Determination – document that provides guidance on hospice eligibility) as her primary tool. MD1 stated she is responsible for signing the CTIs (Certification of Terminal Illness - written certification statements from the medical director of the hospice; certification must specify the individual's prognosis is for a life expectancy of six months or less if the terminal illness runs its normal course. Certifications and recertification must include a brief narrative explanation of the clinical findings a life expectancy of six months or less). MD1 stated that she ";generally" will copy and paste the nurses notes into the CTI ";Physician Narrative" section. MD1 stated that she completes the CTIs on admission and before the expiration of the patient second period. MD1 stated that her signature on the patients CTI, indicates that the patient has a medical condition of 6 months or less if the disease continues its normal course. During a telephone interview on 10/8/2023 at 9:02 a.m. with Patient 2s caregiver (CG1), CG1 stated that Patient 2 had been with the HA for about 500 days and she received a call from the HA recently informing her that P1 was going to be discharge from hospice services. CG1 stated that Patient 2 had terminal dementia (memory loss) but ";God knows how long he has". CG1 stated Patient 2 was not seen by the HAs MD1. CG1 stated she requested and received a letter from the HA and the letter indicated, Patient 1 was receiving hospice services and Patient 2 had six months or less to live. CG1 stated, ";This is a lingering disease, Im sure he has more than six months to live." During a concurrent telephone interview and record review on 10/8/2023 at 1:25 p.m. with the MD1 of Patient 2s EMR, MD1 stated ";Things have fallen through the cracks for this patient." MD1 stated that she was unable to answer any other questions about Patient 2 because she did not have a note documented for this patient. MD1 stated that she was not aware LVN1 was signing the CTI. MD1 stated, ";I sign so many things, if my signature is there, I have to say that is my signature. I havent shared my logging information, as far as I can recall, no." A review of Patient 3s Personal Information indicated Patient 3 had a SOC date of 9/15/2023 with diagnoses of chronic obstructive pulmonary disease (COPD difficulty breathing) and chronic diastolic congestive heart failure (weak heart, which causes fluid buildup). A review of Patient 3s Physician Certification for Hospice Benefit under section ";Physician - CTI" Certificate number one dated 9/15/2023 to 12/13/2023, indicated sections ";RN Assessment Narrative, Physician Narrative – Face to Face Summary, Certifying Physician Summary" were left blank. It also indicated form was not signed MD1. Form also indicated ";I attest/confirm I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". During a concurrent telephone interview and record review on 10/8/2023 at 1:45 p.m. with MD1 of Patient 3s EMR, MD1 stated that P3s initial CTI was incomplete because it did not have her signature. MD1 stated, ";If its not signed, we are behind on our documentation and have begun care without former certification." A review of Patient 4s Personal Information indicated Patient 4 had a SOC date of 10/20/2022 with diagnoses including heart disease. A review of Patient 4s EMR on 10/6/2023 at 4:14 p.m., Physician Certification for Hospice Benefit under section ";Physician - CTI" Certificate #1 dated 10/20/2022 to 11/17/2023, indicated sections ";Physician Narrative – Face to Face Summary, Certifying Physician Summary" were left blank. It also indicated form was not signed MD1. Form also indicated ";I attest/confirm I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient" During a telephone interview on 10/7/2023 at 6:44 p.m. with Patient 4, Patient 4 stated she was referred to the HA from the assisted living facility she used to reside in. Patient 4 stated she knew she was not a hospice patient, but when License Vocational Nurse 1 (LVN1) visited her, LVN1 told her that hospice agency has broaden their qualifications. Patient 4 stated she was unable to afford supplies, which now she gets from the HA. Patient 4 stated, she has not seen or spoken to the HAs doctor. Patient 4 stated that she has never been told by any doctor that she has six months or less to live. Patient 4 stated, ";I understand that it seems odd that they would take me at the beginning as hospice patient, if I was going to live. At the same time, I am very much alive." During an interview on 10/8/2023 at 10:35 a.m. with the Director of Patient Care Services Designee (DD), DD stated that the initial CTI has to be signed by MD1, within 48 hours of admission. DD stated that the CTI indicates that a doctor determines a patient qualifies for hospice care. DD stated a CTI is generated by a Hospice MD. DD stated that a doctors responsibility is to review and write a summary and sign the CTI within 48 hours of admission. DD stated that the MDs signature indicates the CTI is completed. DD stated that if there is a physical CTI that is sent to the HA, an HA staff can verify the signature on their EMR. DD stated that the physical CTI should be uploaded. DD stated that she does not think they have any physical CTIs in the office. During a concurrent telephone interview and record review on 10/8/2023 at 2 p.m. with MD1 of Patient 4s EMR, MD1 stated she was unable to state if she visited Patient 4, because there was no documentation. MD1 stated the Patient 4s initial CTI was not filled out. MD1 stated, ";I dont know what happened in this case, I dont have the documentation to support anything so I cant comment on what happened. We dont have a great system to remind me of when documentation is due." MD1 stated she was unable to state the hospice criteria for Patient 4. MD1 stated, ";I agree, this is a weak case. Generally, the goal is to document evidence of decline and I think that is why she stayed on services, heart failure and wound issues. It could be stronger." A review of Patient 5s Personal Information indicated Patient 5 had a SOC date of 9/25/2023 with diagnoses including cerebral infarction (disruption of blood flow to the brain). A review of Patient 5s Physician Certification for Hospice Benefit" under section ";Physician - CTI" Certificate number two dated 9/25/2023 to 12/23/2023, indicated sections ";RN Assessment Narrative, Physician Narrative – Face to Face Summary, Certifying Physician Summary" were left blank. It also indicated form was not signed by MD1. The form indicated ";I attest/confirm I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient" During a concurrent telephone interview and record review on 10/8/2023 at 2:07 p.m. with MD1 of Patient 5s EMR, MD1 stated that there was no H&P or nursing assessment documented in Patient 5s EMR. MD1 stated, ";I dont know about this patient yet." MD1 stated that she is unable to answer because there is no nursing evaluation. MD1 stated, ";As of this time I do not know if he is hospice eligible. I would make the assumption that he is, I dont know. I dont know how we ended up with him. I cant give you a lot of information on his case." A review of Patient 6s Personal Information indicated Patient 6 had a SOC date of 9/7/2022 and an End of Care (EOC) date of 8/31/2023, with diagnoses including heart failure (weak pumping of the heart). A review of Patient 6s Physician Certification for Hospice Benefit under section ";Physician - CTI" Certificate number four dated 9/7/2023 to 11/5/2023, indicated section ";Physician Narrative – Face to Face Summary" was left blank. It also indicated the MD1s name was documented on the form and LVN1 electronically documented ";Signature on file verified by (LVN1) on 9/7/2022". The Form indicated ";I attest/confirm I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". During a concurrent telephone interview and record review on 10/8/2023 at 2:20 p.m. with MD1, MD1 stated that Patient 6s initial CTI dated 97/2023 to 11/5/2023, had her electronic signature. MD1 stated that she does not remember if she signed the CTI this past Friday or Saturday. MD1 stated, ";The CTI indicates I signed it on September 7, 2022." A review of Patient 7s Personal Information indicated Patient 7 had a Start of Care (SOC) date of 4/1/2022 and an End of Care (EOC) date of 5/31/2023, with diagnoses including unspecified malignant neoplasm of skin (skin cancer). A review of Patient 7s Physician Certification for Hospice Benefit" under section ";Physician - CTI" Certificate number three dated 4/1/2023 to 5/30/2023, indicated sections ";Physician Narrative – Face to Face Summary, Certifying Physician Summary" were left blank. It also indicated form was not signed by MD1. The Form indicated ";I attest/confirm I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient". A record review of the HAs policy and procedure titled, ";Certification of Terminal Illness" revised November 2020, indicated ";When certifying the patient as terminally ill, the hospice medical director must considerate least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification." A record review of the HAs policy and procedure titled, ";Admission Criteria and Process" revised November 2020, indicated ";The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determinations (LCDs). (HA) will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. The patients physician must order and approve the provision of hospice care. The patient must desire hospice services and be aware of the diagnosis and prognosis, Eligibility criteria will be continually reviewed by the interdisciplinary team to ensure appropriateness of hospice care."

L0668

Based on interview and record review the Hospice Agency (HA) failed to ensure the Medical Director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services for three of 15 sample patients (Patient 2, Patient 4, and Patient 6). These deficient practices resulted in the hospice medical director and/or the hospice attending physicians recertified the patients to continue hospice care and service benefits and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- A review of Patient 2s (P2) medical record form titled ";Personal Information" indicated P2 had a Start of Care (SOC) date of 5/10/2022 with diagnoses including Alzheimers Disease (progressive disease of memory loss). A record review of P2s Electronic Medical Record (EMR) on 10/6/2023 at 1:26 p.m. medical record form titled ";Physician Certification for Hospice Benefit" under ";Physician – CTI" indicated Certificate #2: 8/8/2022 to 11/5/2022, Certificate #3: 11/6/2022 to 1/4/2023, Certificate #4: 1/5/2023 to 3/5/2023, Certificate #5 3/6/2023 to 5/4/2023, Certificate #6: 5/5/2023 to 7/3/2023, Certification #7: 7/4/2023 to 9/1/2023 and Certification #8: 9/2/2023 to 10/31/2023, sections ";Certifying physician summary" and ";Face to Face" were left blank. Forms also indicated they were not signed by the Medical Director 1 (MD1). During a telephone interview on 10/7/2023 at 12:45 p.m. with the Medical Director 1 (MD1), MD1 stated that she provides medical oversite. MD1 stated, ";Primary is to be a medical consultant of day-to-day issues that arrive." MD1 stated that before a patient is admitted, they will screen the patient to see if appropriate for hospice. MD1 stated, ";We dont admit anybody that does not meet hospice criteria." MD1 stated that she is responsible for signing the CTIs. MD1 stated that she ";generally" will copy and paste the nurses notes into the CTI ";Physician Narrative" section. MD1 stated that she completes the CTIs on admission and before the expiration of the patient second period. MD1 stated that her signature on the patients CTI, indicates that the patient has a medical condition of 6 months or less if the disease continues its normal course. During a telephone interview on 10/8/2023 at 9:02 a.m. with P2s daughter (CG1), CG1 stated that P1 had been with the HA for about 500 days and that she received a call from the HA recently informing her that P1 was going to be discharge. CG1 stated that P1 had terminal dementia (memory loss) but ";God knows how long he has". CG1 stated that to her knowledge P1 was not seen by the HAs MD1. CG1 was asked if any physician ever told P1 or the family that he had six month or less to live. CG1 stated that she requested a letter from the HA that said P1 was receiving hospice services, and that was the only document that stated P1 had six months or less to live. CG1 stated, ";This is a lingering disease, Im sure he has more than six months to live." During a concurrent telephone interview and record review on 10/8/2023 at 1:25 p.m. with the MD1 of P2s EMR, MD1 stated ";Things have fallen through the cracks for this patient." MD1 stated that she was unable to answer any other questions about P2 because she did not have a note documented for this patient. A review of Patient 4s (P4) medical record form titled ";Personal Information" indicated P4 had a Start of Care (SOC) date of 10/20/2022 with diagnoses including heart disease. A record review of P4s EMR on 10/6/2023 at 4:14 p.m. medical record form titled ";Physician Certification for Hospice Benefit" under ";Physician – CTI" indicated Certificate #4: 6/17/2023 to 8/15/2023 and Certificate #5 8/16/2023 to 10/14/2023, sections ";RN Assessment Narrative, Physician Narrative – Face to Face Summary, Certifying Physician Summary" were left blank. It also indicated form was not signed by MD1. A record review of P4s Electronic Medical Record (EMR) on 10/6/2023 at 4:11 p.m. medical record form titled ";Physician Certification for Hospice Benefit" indicated Certificate #6: 10/15/2023 to 12/13/2023, section ";RN Assessment Narrative" was filled out. During a telephone interview on 10/7/2023 at 6:44 p.m. with P4, P4 stated that she was referred to the HA from the assisted living facility she used to reside in. P4 stated that she knew she was not a hospice patient, but when License Vocational Nurse 1 (LVN1) visited her, P4 stated that LVN1 told her that hospice has broaden their qualifications. P4 stated that she was unable to afford supplies, which now she gets from the HA. P4 stated that she has not seen or spoken to the HAs doctor. P4 stated that she has never been told by any doctor that she has six months or less to live. P4 stated, ";I understand that that is for hospice patients. That is why it seems odd that they would take me at the beginning, if I was going to live. At the same time, I am very much alive." During a concurrent telephone interview and record review on 10/8/2023 at 2 p.m. with MD1 of P4s EMR, MD1 stated that she was unable to state if she visited P4, because there was no documentation. MD1 stated the P4s CTIs were not filled out. MD1 stated, ";I dont know what happened in this case, I dont have the documentation to support anything so I cant comment on what happened. We dont have a great system to remind me of when documentation is due." MD1 stated she was unable to state the hospice criteria for P4. MD1 stated, ";I agree, this is a weak case. Generally, the goal is to document evidence of decline and I think that is why she stayed on services, heart failure and wound issues. It could be stronger." A review of Patient 6s (P6) medical record form titled ";Personal Information" indicated P6 had a Start of Care (SOC) date of 9/7/2022 and an End of Care (EOC) date of 8/31/2023, with diagnoses including heart failure (weak pumping of the heart). A record review of P6s EMR on 10/6/2023 at 4:35 p.m. medical record form titled ";Physician Certification for Hospice Benefit" under ";Physician – CTI" indicated Certificate #7: 3/6/2023 to 5/4/2023, Certificate #8: 5/5/2023 to 7/3/2023, and Certificate #9: 7/4/2023 to 9/1/2023, ";RN Assessment Narrative, Physician Narrative – Face to Face Summary, Certifying Physician Summary" were left blank. It also indicated form was not signed by MD1. During an interview on 10/8/2023 at 10:35 a.m. with the Director of Patient Care Services Designee (DD), DD stated that the initial CTI has to be signed by MD1, within 48 hours of admission. DD stated that the CTI indicates that a doctor determines a patient qualifies for hospice care. DD stated a CTI is generated by a Hospice MD. DD stated that a doctors responsibility is to review and write a summary and sign the CTI within 48 hours of admission. DD stated that the MDs signature indicates the CTI is completed. DD stated that if there is a physical CTI that is sent to the HA, an HA staff can verify the signature on their EMR. DD stated that the physical CTI should be uploaded. DD stated that she does not think they have any physical CTIs in the office. A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" revised November 2020, indicated ";Patient approaching recertification will be reviewed for the appropriates of continuation of care based on identifiable criteria and progression of the terminal illness." A record review of the HAs policy and procedure titled, ";Comprehensive Assessment" revised November 2020, indicated ";The assessment should determine: probable prognosis of six (6) months or less...". A record review of the HAs policy and procedure titled, ";Certification of Terminal Illness" revised November 2020, indicated ";A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more than two (2) weeks prior or two (2) calendar days after the first day or each period. The signed and dated certification must be present prior to billing for each recertification period." A record review of the HAs policy and procedure titled, ";Admission Criteria and Process" revised November 2020, indicated ";The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determinations (LCDs). (HA) will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician, if any... The patients physician must order and approve the provision of hospice care... The patient must desire hospice services and be aware of the diagnosis and prognosis... Eligibility criteria will be continually reviewed by the interdisciplinary team to ensure appropriateness of hospice care."

Survey of March 9, 2023

5 findings

L0545

Observed in Record Review. In 1 of 11 patient records reviewed, the written plan of care was not based on the patient's goals and timeframes, settings, and services required to meet those goals. In RR#1, no goals were identified/documented in the hospice plan of care for the patient's identified problems r/t cardiovascular, neurological/mental, musculoskeletal, nutrition, and sleep. This was reviewed and verified with the Director of Patient Care Services Designee.

L0546

Observed in Record Review. In 2 of 11 patient records reviewed, the organization did not plan the patient's care by including all services need for the palliation and management of the terminal illness and related conditions, including interventions to manage pain and symptoms. In RR#1, there were no interventions in the patient's plan of care for the identified problems related to cardiovascular, neurological/mental, musculoskeletal, nutrition, and sleep. This was reviewed and verified with the Director of Patient Care Services Designee.

L0549

Observed in Record Review. In 2 of 11 patient records reviewed, the plan of care did not include all medications and treatments necessary to meet the patient's needs for palliation and management of the terminal illness and related conditions. In RR#2, the COPD patient's plan of care did not include clear orders for home oxygen. The patient's current treatment/medication list in the hospice record included Oxygen 2 liter per nasal cannula prn to keep O2 sat above 92%. This order conflicted with interventions noted on the patient's plan of care for respiratory indicating Oxygen was ordered 2-5 liters/min prn to keep O2 sat above 92%. In RR#3, it was documented the patient had non-healing wounds of the lower extremities. The hospice plan of care did not include the wound care treatment for the leg wound(s). The plan of care orders were clarified and confirmed with the Hospice Medical Director by end of day. This was reviewed and verified with the Director of Patient Care Services Designee.

L0629

Observed in Record Review. In 1 of 5 patient records reviewed with hospice aide services provided, the organization did not supervise staff effectively by assessing the quality of care and services provided by the aide to ensure the patient's needs were met. In RR#8, there was no supervision of the hospice aide documented by the RN every 14 days. This was reviewed and verified with the Director of Patient Care Services Designee.

L0725

Observed in Patient Home. In 1 of 3 home visits conducted, the organization did not manage safety/security risks. In HV#1, the patient's oxygen concentrator was set at 2 liters per nasal cannula. The concentrator was sitting less than three (3) feet from the gas kitchen stove. During the visit, the primary family caregiver pushed the concentrator back next to the stove. The surveyor noted the location of the running concentrator to the caregiver and LVN. When asked by the surveyor, the caregiver indicated the one back-up oxygen e-tank was being stored outdoors. These oxygen safety issues were not identified, with actions taken, by the LVN/hospice staff per safety standards and organizational policy and procedures. Home oxygen safety education was then provided to the caregiver by the LVN by the end of the visit, with safe placement of the patient's oxygen concentrator/e-tank coordinated and confirmed with the caregiver. This was reviewed and verified with the Director of Patient Care Services Designee.

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Federal survey findings only. State licensure findings for hospices are not shown.

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