Every finding on record at Emanuel Hospice Inc

Based on interview, and record review, the hospice agency (HA) failed to ensure the emergency preparedness plan/drill for office and field staff are maintained, updated and completed in an annual basis. This failure had the potential for the staff to lack the knowledge to respond effectively during an emergency/disaster situation. --- During a review of the emergency preparedness plan of the HA on 2/16/23 at 1:05 p.m., the HA did not have evidence of an updated Emergency Preparedness Plan and training/disaster drill for all office and field staff. Last exercise was 9/11/2018. During an interview and concurrent record review with the Director of Nursing Designee (DOND) on 2/16/23 at 1:05 p.m., DOND stated and confirmed that the policy was signed and dated with the previous governing body and not the current governing body. DOND also stated that she could not find written evidence of the field staff receiving Emergency Preparedness training/disaster drill training. The HHA's undated policy and procedure titled "Emergency Operations Plan" indicated all staff shall receive emergency preparedness training appropriate for their position on a yearly basis. Emanuel Hospice Inc. modifies the emergency operations plan based on the evaluation of emergency response exercises and responses to actual emergencies. Reviews and confirms all staff communication procedures and content as well as assigned roles related to essential response functions. Reviews and confirms how the organization will communicate with patient during an emergency.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation regarding Initial and Comprehensive Assessment of Patients was met as follows: The hospice agency failed to conduct accurate comprehensive assessment for three of 14 sampled patients ( Patient 3, 6 and Patient 10). (Refer to L524). 2. The hospice agency failed to ensure the comprehensive assessment included an initial bereavement risk assessment that identified the need for the patient and family, and that bereavement services were offered prior to the death of two of 14 sampled patients (Patient 5 and 8). (Refer to L 531) 3. The hospice agency failed to accurately assess the patient's eligibility for hospice services related to the palliation and management of the terminal illness and related conditions for nine out of 14 sampled patients (Patients 1,2,3,5,6,7,8,9 and 10). (Refer to L532). The cumulative effects of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with the Federal regulations for Initial & Comprehensive Assessment of Patients to ensure highest quality of care are being provided to patients certified to receive the Medicare hospice benefits. --- .

Based on observation, interview and record review, the hospice agency failed to perform an accurate and complete comprehensive assessment for three of 14 sampled patients ( Patient 3, 6 and 10). This deficient practice had a potential to result in Patient 3, 6 and 10 not receiving appropriate care and services that the patients needed. --- 1. A review of Patient 3's face sheet indicated Patient 3 was admitted to hospice on 10/17/22, with a primary diagnosis of hypertensive heart disease without failure disease (is a long-term condition that develops over many years in people who have high blood pressure ). A review of Patient 3's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 2/14/23, indicated the Licensed Vocational Nurse (LVN) was to visit once per week and one visit as needed. The Registered Nurse (RN) was to visit once per two weeks. The spiritual counselor was to visit once per month, and the Volunteer service was declined. On 2/15/23, at 10:48 a.m., a home visit was conducted at Patient 3's residence with RN 1. The patient was observed walking with a steady gait and breathing normally with no exertion. When Patient 3 was asked who buys her groceries, she stated she goes out and takes the bus to buy groceries or asks her roommate when they go out to buy her groceries. Patient 3 also stated the medical social worker came in once to give her wheelchair but no volunteers called or came to visit her. Patient 3 stated "the nurse comes in once in a blue moon! I am not dying. I don't know why I am on hospice, I used to be in home health." Patient 3 also expressed to be discharged from this agency. Patient 3 stated she does not check her blood sugar often and her blood pressure machine needs batteries. On 2/15/23 ,at 11:00 a.m., during an interview with Patient 3's roommate, Roommate stated " I don't know how they got my phone number. I am not the family or caregiver for her. I am just a roommate. She has family that comes in and visits her. I do not want to be responsible for her care." Roommate also stated that the hospice gave her phone number to the doctor without asking her permission. Roommate also stated that the doctor calls her phone number to talk to the patient via "WhatsApp" ( is a messaging app that uses the internet to send messages, images, audio or video). On 2/15/23, at 3:20 p.m., during a phone interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated that she did a telehealth visit with Patient 3 three weeks ago. LVN 1 stated that she checks blood sugar, blood pressure during a telehealth visit. When asked how she checks the vital signs during a telehealth visit , LVN 1 answered " I ask the patient what is her blood sugar and blood pressure." On 2/16/23, at 1:35 p.m., during a phone interview with the Medical Director (MD), MD confirmed that he is the medical director and the attending physician for all the patients in this agency. MD also stated, " I only conduct virtual telemedicine and that is how I decide to admit them to hospice". A request was made to HA to print out the "Doctor's Notes" from Patient 3's electronic medical record. HA provided documentation from the "Supportive Care Medical Group" dated 12/21/22, 11/22/22, 10/26/22 indicated that Patient 3 had a telehealth-Emanuel hospice for symptom management and goals of care clarification. A request was made to the Director of Nursing designee (DOND) to provide their telehealth policy. DOND confirmed they do not have a telehealth policy made available. 2. A review of Patient 6's Face sheet, indicated that Patient 6 had a medical diagnosis of chronic obstructive pulmonary disease (COPD- is a disease that damages the lungs in ways that make it hard to breathe). A review of Patient 6's clinical record revealed there was no initial nurse clinical assessment for the current certification period. A request was made to the office personnel (OP) to print out the comprehensive assessment for Patient 6 on 2/17/23 at 11:30 a.m. On concurrent interview with the OP, OP stated there was no assessment on the electronic medical record for Patient 6. 3. A review of Patient 10's Physician's Certification for Hospice Benefit for the first certification period of 10/31/22 to 1/28/23 indicated that Patient 10 had a medical diagnosis of hypertensive heart disease with heart failure (is a long-term condition that develops over many years in people who have high blood pressure) and chronic obstructive pulmonary disease (COPD- is a disease that damages the lungs in ways that make it hard to breathe). A review of Patient 10's clinical record revealed there was no nurse clinical assessment for this certification period. A request was made to the office personnel (OP) to print out the comprehensive assessment for Patient 10 on 2/17/23 at 11:30 a.m. During a concurrent interview with the OP, OP stated there was no assessment on the electronic medical record for Patient 10. On 2/17/23 at 11:30 a.m., during an interview with the Director of Nursing designee (DOND), DOND confirmed that there was no comprehensive assessment done for Patient 6 and Patient 10 for this certification period. DOND further stated that if there was no comprehensive assessment, the skilled nurse was not following the correct plan of care for Patient 6 and Patient 10. A review of the Patient 10's document titled " Visit Notes", Skilled nursing continued to perform her visits on the following dates : 2/14/23, 2/7/23, 1/31/23 without verification from the medical doctor (MD) or any written doctor's orders for the visit. A review of the HA's policy titled "Comprehensive Assessment" revised April 2016, indicated that a comprehensive assessment will be perfumed by the hospice interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. During the comprehensive patient assessment, all baseline data and other relevant information will be documented in the patient's clinical record. Based upon the findings of the assessment, additional orders will be generated and forwarded to the physician. The physician will be notified to verify the changes in medications, and treatment interventions that require physician approval.

Based on interview and record review, the hospice agency failed to ensure the comprehensive assessment included an initial bereavement risk assessment that identified the need for the patient and family, and that bereavement services were offered prior to the death of two of 14 sampled patients (Patient 5 and 8). This deficient practice resulted in patient and family were not offered bereavement services and may impact their ability to copy with the patient's death. --- 1. A review of Patient 5's clinical record indicated a start of care date (SOC) of 12/10/22, with diagnoses which included heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). A review of Patient 5's Plan of Care summary dated 12/20/22, indicated that a skilled nurse (SN) is scheduled to visit patient once per week for clinical assistance and support and 2 visits as needed for sudden change in patient's condition. Spiritual counselor for initial evaluation of spiritual needs and to provide spiritual support. A review of Patient 5's clinical record indicated that there was no initial bereavement assessment completed. 2. A review of Patient 8's clinical record indicated a start of care date (SOC) of 12/20/22, with diagnoses which included COPD (Chronic obstructive pulmonary disease, is a disease that damages the lungs in ways that make it hard to breathe) A review of Patient 8's Plan of Care summary dated 12/20/22, indicated that a skilled nurse (SN) was scheduled to visit patient once per week for clinical assistance and support and 2 visits as needed for sudden change in patients condition. Spiritual counselor for initial evaluation of spiritual needs and to provide spiritual support. A review of Patient 8's clinical record indicated there was no initial bereavement assessment completed. During an interview with the Director of Nursing Designee (DOND) on 2/17/23, at 11:00 a.m., the DOND stated that a bereavement assessment should be conducted on admission. The DOND confirmed that Patient 5 did not have an initial bereavement assessment conducted on admission found in Patient 8's electronic medical record. A review of the hospice agency's policy and procedures titled, "Bereavement Assessment" revised April 2016, indicated that on admission, the social worker or hospice registered nurse will complete the bereavement risk assessment that will be given to the Bereavement coordinator (BC). The BC will review the bereavement risk assessment to determine the potential needs of the survivors. The BC will develop a plan for intervention, based on the findings of the bereavement follow-up assessment and input from the interdisciplinary group members. The BC will then document the interventions on the bereavement's checklist in the patient's clinical record.

Based on observation, interview, and record review, the hospice agency failed to accurately assess the patient's eligibility for hospice services related to the palliation and management of the terminal illness and related conditions for nine out of 14 sampled patients (Patients 1, 2, 3 ,5, 6, 7, 8, 9, and 10). This deficient practice had the potential to result in the misuse of the hospice of services that could result in a substandard provision of patient care. --- 3. A review of Patient 3s admission record indicated the patient was admitted to the HA on 10/17/22, with a primary diagnosis of hypertensive heart disease without failure (is a long-term condition that develops over many years in people who have high blood pressure) A review of Patient 3's Certificate of Terminal Illness (CTI), dated 10/17/22 to 1/14/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 3 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 2/15/23, at 11 a.m., a home visit was conducted at Patient 3's residence with RN 1. The patient was observed walking with steady gait, breathing normally with no exertion. When Patient 3 also stated that one of the staff from the hospice agency referred her to this hospice agency. Patient 3 stated she was on home health before and wants to be discharged from this hospice agency. 5. A review of Patient 5's clinical record indicated a start of care date (SOC) of 12/20/22, with diagnoses which included heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). A review of Patient 5's CTI, dated 12/20/22 to 1/14/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 5 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis 6. A review of Patient 6s admission record indicated the patient was admitted to the HA on 12/20/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD- is a disease that damages the lungs in ways that make it hard to breathe). A review of Patient 6's CTI, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 6 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory test results, imaging data, history and physical, biopsy results to indicate and support the terminal illness diagnosis. 8. A review of Patient 8s admission record indicated the patient was admitted to the HA on 9/22/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD- is a disease that damages the lungs in ways that make it hard to breathe). A review of Patient 8's CTI, dated 11/21/22 to 1/19/23 , Benefit period #7 indicated the Medical Director signed the attending physician referral section indicated Patient 8 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis 10. A review of Patient 10s admission record indicated the patient was admitted to the HA on 8/2/22, with a primary diagnosis of hypertensive heart disease ( is a long term condition that develops over many years in people who have high blood pressure). A review of Patient 10's CTI, dated 1/29/22 to 3/29/23, Benefit period #3 indicated the Medical Director signed the attending physician referral section indicated Patient 10 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis There was no documentation for laboratory results, imaging data, history and physicals, biopsy results to indicate and the support the terminal illness diagnosis. On 2/17/23, at 1 p.m., during an interview with the DOND (director of nursing designee), DOND stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. On 2/17/23, at 2 p.m., during a phone interview with Medical Director 1, he stated that he was not the attending physician and he does not know who the attending physician for Patients 1, 2, 3, 5, 6, 7, 8, 9 and 10. He stated since this patient was admitted to their hospice service, he is now the patient's attending physician, that he signed the referral attending physician section because no one will sign it.. He further stated that he did not do a face-to-face encounter with Patient 1 during her admission to hospice service but he determines the patient is eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. A review of the policy "Admission Criteria and Process", indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination. Emanuel Hospice Inc. will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. The patient's physician must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate and be willing to discuss the patients resuscitation status with the patient's resuscitation status with the patient and family/caregiver. 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. a. A review of Patient 1's face sheet indicated admission to hospice on 8/16/22, with primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). It was indicated in the face sheet that Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 1's Certificate of Terminal Illness (CTI), dated 8/16/22 to 11/13/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. On 2/15/23, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 1. The patient was observed sing at the dining room. When Caregiver 1 was asked if Patient 1's attending physician referred him to hospice service, she stated no. LVN 1 also stated that one of the staff from the hospice agency referred her to this hospice agency. On 2/20/23, at 12 p.m., during a phone interview with Physician 1, he stated that he was the attending physician for Patient 1 but he does not need hospice service at all. b. A review of Patient 2's face sheet indicated admission to hospice on 8/29/22, with primary diagnosis of unspecified heart disease. It was indicated in the face sheet that Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 2's Certificate of Terminal Illness (CTI), dated 8/29/22 to 11/26/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 2 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. c. A review of Patient 7's face sheet indicated admission to hospice on 10/12/22, with primary diagnosis of hypertensive heart disease. It was indicated in the face sheet that Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 7's Certificate of Terminal Illness (CTI), dated 10/12/22 to 1/16/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 7 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. d. A review of Patient 9's face sheet indicated admission to hospice on 8/16/22, with primary diagnosis of chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe). It was indicated in the face sheet that Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 9's Certificate of Terminal Illness (CTI), dated 8/16/22 to 11/13/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. On 2/20/23, at 2 p.m., during a phone interview with Medical Director 1, he stated that he was not the attending physician, and he does not know who the attending physician for Patients 1, 2, 7, and 9. He stated since this patient was admitted to their hospice service, he is now the patient's attending physician, that he signed the referral attending physician section because no one will sign it.. He further stated that he did not do a face-to-face encounter with Patient 1 during her admission to hospice service but he determines the patient is eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. On 1/20/23, at 1 p.m., during an interview with the DPCSD (director of patient care services designee), she stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. A review of the policy "Admission Criteria and Process", indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Interdisciplinary Group (IDG), Care Planning, and Coordination of Services was met as follows: 1. The hospice agency failed to have every member of the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) participated in the interdisciplinary group meeting for 10 of 14 sample patients, (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). (Refer to L541) 2. The hospice agency failed to ensure the IDG including the Medical Director had communicated with the patient's primary physician to verify the patient's eligibility for hospice care services for nine of 14 sampled patients, (Patient 1, 2, 3, 5, 6, 7, 8, 9 and 10). (Refer to L554) The cumulative effect of these systemic practices resulted in the failure of the hospice agency to deliver statutorily mandated compliance with the IDG, Care Planning, and Coordination of Services to ensure the highest quality of care are provided to the patients accurately assessed to receive hospice care and services.

Based on interview and record review, the hospice agency failed to ensure every member of the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) participated in the interdisciplinary group meeting for 10 of 14 patients, (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10). This deficient practice had the potential to result in members of the IDG not contributing to the patients' comprehensive and ongoing assessments and care planning process. --- 3. A review of Patient 3s admission record indicated the patient was admitted to the HA on 10/17/22, with a primary diagnosis of hypertensive heart disease without failure ( is a long term condition that develops over many years in people who have high blood pressure) A review of Patient 3s medical record titled, ";POC/IDG Review", did not indicate the Hospice Medical Director, MSW (Medical Social Worker), the RN (registered nurse) and the Chaplain attended IDT meetings on 2/10/23, 1/27/23, 1/13/23, 12/30/22 and 12/16/22 5. A review of Patient 5s admission record indicated the patient was admitted to the HA on 12/20/22, with a primary diagnosis of heart failure (a chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood ) A review of Patient 5s medical record titled, ";POC/IDG Review", did not indicate the Hospice Medical Director, MSW (Medical Social Worker), the RN (registered nurse) and the Chaplain attended IDT meetings on 2/10/23 and 12/20/22. 6. A review of Patient 6s admission record indicated the patient was admitted to the HA on 12/20/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD- is a disease that damages the lungs in ways that make it hard to breathe). A review of Patient 6s medical record titled, ";POC/IDG Review", did not indicate the Hospice Medical Director, MSW (Medical Social Worker), the RN (registered nurse) and the Chaplain attended IDT meetings on 2/10/23 and 12/20/22. 8. A review of Patient 8s admission record indicated the patient was admitted to the HA on 9/22/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD- is a disease that damages the lungs in ways that make it hard to breathe). A review of Patient 8s medical record titled, ";POC/IDG Review", did not indicate the Hospice Medical Director, MSW (Medical Social Worker), the RN (registered nurse) and the Chaplain attended IDT meetings on 2/10/23, 1/27/23, 1/13/23, 12/30/22 and 12/16/22. 10. A review of Patient 10s admission record indicated the patient was admitted to the HA on 8/2/22, with a primary diagnosis of hypertensive heart disease ( is a long term condition that develops over many years in people who have high blood pressure). A review of Patient 10s medical record titled, ";POC/IDG Review", did not indicate the Hospice Medical Director, MSW (Medical Social Worker), the RN (registered nurse) and the Chaplain attended IDT meetings on 2/10/23 and 8/2/22 On 2/17/23 at 1:20 p.m., during an interview with the Director of Nursing designee (DOND) , DOND stated that the members of the IDG comprises of the Physician, the registered nurse, social worker and other staff that attends the IDG meeting. DOND stated that if the document is not signed electronically, there was no IDG meeting conducted. DOND stated it is important to conduct regular IDG meetings to discuss the patients plan of care. A review of the HA's policy titled " Interdisciplinary Group Coordination of Care" revised April 2016, indicated that care will be provided by an interdisciplinary group (IDG) made up of physicians, nurses, social workers, hospice aides, home makers, clergies, counselors, volunteers and therapists. When the patient requires services from the IDG, the Registered nurse (RN) case manager will be responsible for cooperative care planning to ensure goals, interventions and outcomes are palliative in nature. A review of the HA's policy titled " Interdisciplinary Group Meeting" revised April 2016 indicated the IDG will meet on a regular basis to discus patient/family/caregiver changes and progress and updates to the plan of care, deaths, and changes in the patient and family/caregiver circumstances , referrals and admissions/certification and recertification of patients on the hospice program. a. A review of Patient 1's clinical record indicated a start of care date (SOC) of 8/16/22, with a diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). A review of Patient 1's Plan of Care (POC)/Interdisciplinary Group (IDG) review indicated that on dates 8/16, 8/25/22, and 9/22/22, the Hospice Medical Director, MSW (Medical Social Worker), the RN (registered nurse) and the Chaplain did not attend the IDG meetings. b. A review of Patient 2's clinical record indicated a start of care date (SOC) of 8/29/22, with a diagnosis of unspecified heart disease. A review of Patient 1's Plan of Care POC/IDG review indicated on dates 8/29/22, 9/12, 9/26/22 and 10/10/22, the Hospice Medical Director, MSW (Medical Social Worker), the RN (registered nurse) and the Chaplain did not attend the IDG meetings. c. A review of Patient 4's clinical record indicated a start of care date (SOC) of 1/8/23, with a diagnosis of malignant neoplasm of gallbladder (cancer that develops in the gallbladder). A review of Patient 4's Plan of Care POC/IDG review indicated that on dates 1/13, 1/27/23 and 2/10/23, the Hospice Medical Director, MSW (Medical Social Worker), the RN (registered nurse) and the Chaplain did not attend the IDG meetings. d. A review of Patient 7's clinical record indicated a start of care date (SOC) of 10/12/22, with a diagnosis of hypertensive heart disease. A review of Patient 7's Plan of Care POC/IDG review indicated that on dates 10/12, 10/26/22, 11/9, 11/23/22 and 12/7/22, the Hospice Medical Director, MSW (Medical Social Worker), the RN (registered nurse) and the Chaplain did not attend the IDG meetings. e. A review of Patient 9's clinical record indicated a start of care date (SOC) of 8/16/22, with a diagnosis of chronic obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe). A review of Patient 7's Plan of Care POC/IDG review indicated that on dates 8/16, 8/30/22, 9/14, 9/28/22 and 10/11/22, the Hospice Medical Director, MSW (Medical Social Worker), the RN (registered nurse) and the Chaplain did not attend the IDG meetings. On 2/17/23 at 1:20 p.m., during an interview with the DPCSD (director of patient care services designee), she stated that the members of the IDG comprises of the physician, registered nurse, social worker and other staff that attends the IDG meeting. DPCSD also stated that if the document is not signed electronically, there was no IDG meeting conducted. DPCSD further stated it is important to conduct regular IDG meetings to discuss the patients plan of care.

Based on observation, interview and record review, the hospice agency failed to ensure the Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), including the Medical Director had communicated with the patients' primary physician to verify the patient's eligibility for hospice care services for nine out of 14 sampled patients, (Patient 1, 2, 3, 5, 6, 7, 8, 9 and 10). This deficient practice resulted in certifying patients for hospice services without clinical evidence to support the diagnoses and allowed the hospice agency to provide care/services to the patients who were not qualified to receive the Medicare hospice benefit. --- A review of Patient 3's face sheet indicated Patient 3 was admitted to hospice on 10/17/22, with a primary diagnosis of hypertensive heart disease without failure disease (is a long-term condition that develops over many years in people who have high blood pressure ). It was indicated on the face sheet that Medical Director (MD) was the Referring/Attending /Patient's choice doctor. A review of Patient 3's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 2/14/23, indicated the Licensed Vocational Nurse (LVN) was to visit once per week and one visit as needed. The Registered Nurse (RN) was to visit once per two weeks. The spiritual counselor was to visit once per month, and the Volunteer service was declined. A review of Patient 3's Certificate of Terminal Illness (CTI), dated 10/17/22 to 1/14/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section which indicated Patient 3 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 2/15/23, at 10:48 a.m., a home visit was conducted at Patient 3's residence with RN 1. The patient was observed walking with a steady gait and breathing normally with no exertion. When Patient 3 was asked who buys her groceries, she stated she goes out and takes the bus to buy groceries or asks her roommate when they go out to buy her groceries. Patient 3 also stated the medical social worker came in once to give her wheelchair but no volunteers called or came to visit her. Patient 3 stated "the nurse comes in once in a blue moon! I am not dying. I don't know why I am on hospice, I used to be in home health." Patient 3 also expressed to be discharged from this agency. On 2/15/23 at 11:00 a.m., during an interview with Patient 3's roommate, Roommate stated " I don't know how they got my phone number. I am not the family or caregiver for her. I am just a roommate. She has family that comes in and visits her. I do not want to be responsible for her care." Roommate also stated that the hospice gave her phone number to the doctor without asking her permission. On 2/15/23 at 11:45 a.m., during an interview with RN 1 after the home visit, stated , I was looking for her hospice revocation form and it was not inside the hospice book. RN 1 stated that based on her assessment , Patient 3 in "not hospice appropriate." On 2/16/23 at 1:35 p.m., during a phone interview with the Medical Director (MD), MD confirmed that he is the medical director and the attending physician for all the patients in this agency. MD also stated " I only conduct virtual telemedicine and that is how I decide to admit them to hospice". A review of the HA's policy titled "Admission criteria and Process" revised April 2016, indicated that the patient must identify a family member/caregiver or legal representative who agrees to be the primary support. caregiver if and when needed. The patient must have a life-limiting illness with a life expectancy of 6 months or less and the patient must desire hospice services, and be aware of the diagnosis and prognosis. a. A review of Patient 1's face sheet indicated admission to hospice on 8/16/22, with primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). It was indicated in the face sheet that Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 1's Certificate of Terminal Illness (CTI), dated 8/16/22 to 11/13/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. On 2/15/23, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 1. The patient was observed singing at the dining room. Caregiver 1 was asked if Patient 1's attending physician referred him to hospice service, she stated no. She also stated that one of the staff from the hospice agency referred her to this hospice agency. On 2/20/23, at 12 p.m., during a phone interview with Physician 1, he stated that he was the attending physician for Patient 1 but he does not need hospice service at all. b. A review of Patient 2's face sheet indicated admission to hospice on 8/29/22, with primary diagnosis of unspecified heart disease. It was indicated in the face sheet that Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 2's Certificate of Terminal Illness (CTI), dated 8/29/22 to 11/26/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 2 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. c. A review of Patient 7's face sheet indicated admission to hospice on 10/12/22, with primary diagnosis of hypertensive heart disease. It was indicated in the face sheet that Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 7's Certificate of Terminal Illness (CTI), dated 10/12/22 to 1/16/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 7 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. d. A review of Patient 9's face sheet indicated admission to hospice on 8/16/22, with primary diagnosis of chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe). It was indicated in the face sheet that Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 9's Certificate of Terminal Illness (CTI), dated 8/16/22 to 11/13/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. On 2/20/23, at 2 p.m., during a phone interview with Medical Director 1 (MD1), stated that he was not the attending physician, and he does not know who the attending physicians for Patients 1, 2, 7 and 9. MD1 stated since these patients were admitted to their hospice service, he was now the patients' attending physician, signed the referral attending physician section because no one will sign it. MD1 further stated that he did not do a face-to-face encounter with Patient 1 during her admission to hospice service but he determined the patient was eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. On 1/20/23, at 1 p.m., during an interview with the DPCSD (director of patient care services designee), she stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. A review of the policy "Admission Criteria and Process", indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local

Based on interview and record review, the agency failed to ensure the Condition of Participation for Quality assessment/performance improvement is met as follows: The hospice agency failed to ensure a performance improvement projects (PIP, a concentrated effort on a particular problem in one area of the facility or facility wide that involves gathering of information systematically to clarify issues or problems and intervening for improvements) were conducted every year. (Refer to L572) The cumulative effect of these systemic practices resulted in the agencies failure to ensure that issues, problems and other interventions necessary to the improvement of quality patient care will not be discussed and presented to the caregivers involved in direct patient care. --- .

Based on interview and record review, the hospice agency failed to ensure a performance improvement project (PIP, a concentrated effort on a particular problem in one area of the facility or facility wide involving gathering of information systematically to clarify issues or problems, and intervening for improvements) were conducted every year. This failure had the potential to affect the highest quality of care provided to all the patients under agency's care. --- A request was made on 2/16/2022, at 11:00 a.m., to the Director of Nursing Designee (DOND) for the performance improvement projects (PIP, an ongoing program for improvement that focuses on clinical and nonclinical areas) that were derived from the data collected from the Quality Assurance and Performance Improvement (QAPI, the coordinated application of two mutually‑reinforcing aspects of a quality management system to maintain and improve safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving) program. On 2/16/23, at 11:00 a.m., during an interview, the DOND stated she was aware of the requirement, but she was not in charge of the QAPI and PIP. DOND also stated that she only does consulting for this agency and supervises office staff. DOND could not provide any evidence of past projects. A review of the agency's QAPI/PIP did not indicate that the governing body discussed their QAPI/PIP as evidenced by the Director of Patient care Services (DPCS) signature for the meeting. Team members of the agency's governing body did not have signatures to provide that they attended the meeting. The agency's policy and procedure titled "Quality Assessment and Performance Improvement Plan and Program" indicated the agency will have an organized system assessing and improving the quality of care and services. This system shall be designed to improve performance on a systematic and continuous basis. The policy stated there should be coordination of performance improvement activities.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation regarding Volunteers was met as followed: The hospice agency failed to ensure volunteer service program was maintained and was offered/ provided to the patients for 14 of 14 sample patients (Patient 1, Patient 2,Patient 3, Patient 4,Patient 5, Patient 6, Patient 7,Patient 8, Patient 9,Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) (Refer to L644). The hospice agency failed to retain and recruit volunteer services program 14 of 14 sampled patients (Patient 1,Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14 ). (Refer to L645). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Volunteer Services to ensure highest quality of patient care is provided to patients certified to receive the hospice benefits. --- .

Based on observation, interview and record review, the hospice agency (HA) failed to ensure volunteer service program was maintained and offered/ provided to the patients for 14 of 14 sample patients (Patient1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This deficient practice prevented the patients from receiving the benefits from the volunteer program. --- 3. A review of Patient 3's face sheet (admission record) indicated patient 3 was admitted to the hospice agency on 10/17/22, with primary diagnosis of hypertensive heart disease (is a long-term condition that develops over many years in people who have high blood pressure) without failure. A review of Patient 3's "Plan of Care (POC)" dated 2/14/23, indicated the Skilled Nurse (SN) visit was once per week and as needed, the Medical Social Worker (MSW) visit was one time then as needed. On 2/15/2022, at 11:00 a.m., a home visit was conducted at Patient 3's residence. Patient 3 was observed to be living with 2 roommates, sitting on her couch at her bedroom, alert and oriented, fairly groomed and able to move both upper and lower extremities. On 2/15/23, at 11 a.m., during an interview with Patient 3, when asked if he was offered volunteer services by the hospice agency, she stated she was not offered at all. Patient 3 further stated that she wanted help to run errands for her and she was upset that she was not told that the hospice agency can offer these services to her. On 2/15/23, at 11 a.m., during an interview with the Patient 3's roommate, stated "I don't know why they call me as caregiver, I am only a roommate and we all rent this house. She has an immediate family that they can call. I am not responsible for her." A review of the Patient 3's clinical record indicated there was no documented evidence the patient was informed or being offered of their volunteer services as part of their core services. On 2/16/23 at 11:00 a.m., with the Director of nursing designee (DOND) stated "we don't have a volunteer and do not utilize volunteer services currently. On 2/17/23, at 2 p.m., during an interview with DOND (director of nursing designee), when asked if agency has an active volunteer coordinator staff, she stated the hospice agency had no volunteer coordinator at this time. She also stated that the visiting nurse did not offer volunteer services for Patient's 1 to 14. A review of the HA's policy titled " Patient education Process" revised April 2016 indicated community resources will be accessed, as appropriate and available, based on patient and family/caregiver needs. Patient and family/caregiver's education will be interdisciplinary and interactive as appropriate to the plan of care. At interdisciplinary group meetings (IDG) , patient education, and learning needs/processes will be discussed by all clinicians involved in the care. The patient's and family/caregiver's knowledge, skills and behaviors will be assessed during hospice visits. Re-education, when appropriate, will be provided. The agency's policy and procedure titled, "Volunteer Services", dated 4/2016, indicated the qualified volunteers provide appropriate services in accordance with the interdisciplinary plan of care and hospice program needs. A review of Patient 1's face sheet indicated admission to hospice on 8/16/22, with primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). It was indicated in the face sheet that Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 1's Certificate of Terminal Illness (CTI), dated 8/16/22 to 11/13/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. On 2/15/23, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 1. The patient was observed sitting on a couch at the dining room. at 11:15 a.m., during an interview with Patient 1, when asked if he was offered volunteer services by the hospice agency, he stated he was not offered at all. He further stated that he wanted help to run errands for him and he was upset that he was not told the hospice agency can offer those services to him. A review of the patient's clinical record indicated there was no documented evidence the patient was informed or being offered of their volunteer services as part of their core services. On 2/17/23, at 2 p.m., during an interview with DPCSD (director of patient care services designee), when asked if agency has an active volunteer coordinator staff, she stated the hospice agency had no volunteer coordinator at this time. DPCSD also stated the visiting nurse did not offer volunteer services for Patients 1 to 14.

Based on observation, interview and record review, the hospice agency (HA) failed to recruit and retain volunteer services program to provide direct patient care services to 14 of 14 sampled patients (Patients 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13 and Patient 14). This deficient practice prevented the patients from receiving hospice care and benefits from the volunteers in order to meet their needs identified in their plans of care. --- A review of Patient 3's face sheet (admission record) indicated patient 3 was admitted to the hospice agency on 10/17/22, with primary diagnosis of hypertensive heart disease (is a long-term condition that develops over many years in people who have high blood pressure) without failure. A review of Patient 3's "Plan of Care (POC)" dated 2/14/23, indicated the Skilled Nurse (SN) visit was once per week and as needed, the Medical Social Worker (MSW) visit was one time then as needed. On 2/15/2022, at 11:00 a.m., a home visit was conducted at Patient 3's residence. Patient 3 was observed to be living with 2 roommates, sitting on her couch at her bedroom, alert and oriented, fairly groomed and able to move both upper and lower extremities. On 2/15/23, at 11:00 a.m., during an interview with Patient 3, when asked if he was offered volunteer services by the hospice agency, she stated she was not offered at all. She further stated that she wanted help to run errands for her and she was upset that she was not told that the hospice agency can offer those services to her. On 2/15/23 at 11:00 a.m., during an interview with the Patient 3's roommate, stated "I don't know why they call me as caregiver , I am only a roommate and we all rent this house. She has an immediate family that they can call. I am not responsible for her." A review of the patient 3's clinical record indicated there was no documented evidence the patient was informed or being offered of their volunteer services as part of their core services. On 2/16/23 at 11:00 a.m., with the Director of nursing designee (DOND) stated "we don't have a volunteer and do not utilize volunteer services currently. A review of the HA's policy titled " Patient education Process" revised April 2016 indicated community resources will be accessed, as appropriate and available, based on patient and family/caregiver needs. Patient and family/caregiver's education will be interdisciplinary and interactive as appropriate to the plan of care. At interdisciplinary group meetings (IDG) , patient education, and learning needs/processes will be discussed by all clinicians involved in the care. The patient's and family/caregiver's knowledge, skills and behaviors will be assessed during hospice visits. Re-education, when appropriate, will be provided. The agency's policy and procedure titled, "Volunteer Services", dated 4/2016, indicated the qualified volunteers provide appropriate services in accordance with the interdisciplinary plan of care and hospice program needs.

Based on record review, and interview, the hospice agency failed to ensure an appointed and/or designated person in the governing body assume the full legal authority, responsibility, and management of the hospice agency and failed to ensure the appointed administrator (ADMIN) and Director of patient care services (DPCS) are both available to manage the day-to-day operation of the hospice. This deficient practice has the potential risk in the mismanagement of the hospice and provision of a substandard level of care that could affect the health and safety of the patients certified to receive the hospice benefits. --- During the recertification survey on 2/14/23 to 2/17/23, the Administrator (ADMIN) was not present in the office and arrived the end of the first day of the survey. The Director of Patient care Services (DPCS) also was not present during the survey. On 2/16/23 at 11:00 a.m., the survey team requested the DON designee to have the ADMIN and the DPCS come to the agency. During an interview with the DON designee on 2/16/23 at 1:20 p.m., stated that the members of the governing body included the Administrator, Medical Director (MD), Director of Patient Care Services and the staff assigned to the patient's care. DON designee stated that she does not handle the clinical part and only supervises the office staff. On 2/17/23 at 11:15 a.m., the survey team requested the DON designee for both the Administrator and the DPCS to attend the exit conference as part of their survey. Both Admin and DPCS did not arrive till the end of the survey. A review of the HA's policy titled " Job descriptions: Administrator" revised April 2016 indicated the Administrator or the Executive Director is responsible for the overall direction of the day to day operations of the hospice services. He or she is responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly and the delegation to and coordination of hospice personnel evaluations; responsible for establishing standards of care to comply with federal and state regulations and guidelines. The executive director/administrator establishes, implements and evaluates goals and objectives for hospice services that meet and promote the standards of quality and contribute to the total organization and philosophy.

Based on interview and record review , the hospice agency (HA) failed to assess the skills and competence of all individuals furnishing care, including volunteers furnishing services, and, as necessary, provide in-service training and education programs where required. This deficient practice has the potential to result in a substandard provision of patient care and services. --- A review of the HAs personnel files on 2/16/23 indicated that all field staff had their performance evaluations during their initial hire date. There was no other documented evidence in all personnel files of yearly performance evaluations. On 2/16/23 at 11:00 a.m., during an interview with the Director of Nursing Designee (DOND) stated that she only supervises the office staff and does not do any clinical evaluations in the office. A review of the HAs policy titled "; Job description: Registered Nurse" revised April 2016, indicated the Registered Nurse assumes responsibility for personnel growth and development and maintains and upgrades professional knowledge and practice skills through attendance and participation in continuing education and In-service classes. A review of the HAs policy titled "; Governing Body" revised April 2016 indicated the essential job functions and responsibilities is to ensure staff development including orientation, in-service, continuing education, competency testing and quality assessment performance improvement.

Based on observation, interview and record review, the hospice agency failed to ensure the Condition of Participation for Medical Director was met as follows: 1. The hospice agency failed to ensure the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications of nine of 14 sampled patients (Patients 1, 2, 3, 5, 6, 7, 8, 9 and 10) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. (Refer to L 667) 2. The hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included, conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness for nine of 14 sampled patients (Patient 1, 2, 3, 5, 6, 7, 8, 9, and 10). (Refer L 669) The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services. --- .

Based on observation, interview, and record review, the hospice agency failed to ensure the medical director conducted an accurate assessment, review, and verified the patient clinical information, necessary for initial certifications for nine of 14 sampled patients (Patients 1, 2, 3, 5, 6, 7, 8, 9 and 10) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The agency failed to obtain and review the patients documented clinical information necessary for initial certification of hospice care and services that included patient's history and physical, laboratory and imaging data, and biopsy results. These deficient practices resulted in the hospice medical director and/or the hospice attending physicians to certify the patients for hospice care, without documentation of clinical evidence to support the terminal illness diagnoses that could result in the lack of and inappropriate care being provided to the patients. --- 3. A review of Patient 3s admission record indicated the patient was admitted to the HA on 10/17/22, with a primary diagnosis of hypertensive heart disease without failure ( is a long-term condition that develops over many years in people who have high blood pressure) A review of Patient 3's Certificate of Terminal Illness (CTI), dated 10/17/22 to 1/14/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 3 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 2/15/23, at 11 a.m., a home visit was conducted at Patient 3's residence with RN 1. The patient was observed walking with steady gait, breathing normally with no exertion. When Patient 3 also stated that one of the staff from the hospice agency referred her to this hospice agency. Patient 3 stated she was on home health before and wants to be discharged from this hospice agency. 5. A review of Patient 5's clinical record indicated a start of care date (SOC) of 12/20/22, with diagnoses which included heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). A review of Patient 5's CTI, dated 12/20/22 to 1/14/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 5 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis 6. A review of Patient 6s admission record indicated the patient was admitted to the HA on 12/20/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD- is a disease that damages the lungs in ways that make it hard to breathe). A review of Patient 6's CTI, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 6 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. 8. A review of Patient 8s admission record indicated the patient was admitted to the HA on 9/22/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD- is a disease that damages the lungs in ways that make it hard to breathe). A review of Patient 8's CTI, dated 11/21/22 to 1/19/23 , Benefit period #7 indicated the Medical Director signed the attending physician referral section indicated Patient 8 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. 10. A review of Patient 10s admission record indicated the patient was admitted to the HA on 8/2/22, with a primary diagnosis of hypertensive heart disease ( is a long term condition that develops over many years in people who have high blood pressure). A review of Patient 10's CTI, dated 1/29/22 to 3/29/23, Benefit period #3 indicated the Medical Director signed the attending physician referral section indicated Patient 10 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis On 2/17/23, at 1 p.m., during an interview with the DOND (director of nursing designee), DOND stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. On 2/17/23, at 2 p.m., during a phone interview with Medical Director 1, he stated that he was not the attending physician, and he does not know who the attending physician for Patients 1,2,3, 5, 6, 7, 8, 9 and 10. He stated since this patient was admitted to their hospice service, he is now the patient's attending physician, that he signed the referral attending physician section because no one will sign it.. He further stated that he did not do a face-to-face encounter with Patient 1 during her admission to hospice service but he determines the patient is eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. A review of the policy "Admission Criteria and Process", indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination. Emanuel Hospice Inc. will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. The patient's physician must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate and be willing to discuss the patients resuscitation status with the patient's resuscitation status with the patient and family/caregiver. 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. . a. A review of Patient 1's face sheet indicated admission to hospice on 8/16/22, with primary diagnosis of Alzheimer's disease (a progressive disease that destroys memory and other important mental functions). It was indicated in the face sheet that Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 1's Certificate of Terminal Illness (CTI), dated 8/16/22 to 11/13/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. On 2/15/23, at 11 a.m., a home visit was conducted at Patient 1's residence with LVN 1. The patient was observed sing at the dining room. When Caregiver 1 was asked if Patient 1's attending physician referred him to hospice service, she stated no. She also stated that one of the staff from the hospice agency referred her to this hospice agency. On 2/20/23, at 12 p.m., during a phone interview with Physician 1, he stated that he was the attending physician for Patient 1 but he does not need hospice service at all. b. A review of Patient 2's face sheet indicated admission to hospice on 8/29/22, with primary diagnosis of unspecified heart disease. It was indicated in the face sheet that Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 2's Certificate of Terminal Illness (CTI), dated 8/29/22 to 11/26/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 2 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. c. A review of Patient 7's face sheet indicated admission to hospice on 10/12/22, with primary diagnosis of hypertensive heart disease. It was indicated in the face sheet that Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 7's Certificate of Terminal Illness (CTI), dated 10/12/22 to 1/16/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 7 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. d. A review of Patient 9's face sheet indicated admission to hospice on 8/16/22, with primary diagnosis of chronic obstructive pulmonary disease (a group of lung disease that block airflow and make it difficult to breathe). It was indicated in the face sheet that Medical Director 1 was the Referring/Attending /Patient choice doctor. A review of Patient 9's Certificate of Terminal Illness (CTI), dated 8/16/22 to 11/13/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 1 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis. On 2/20/23, at 2 p.m., during a phone interview with Medical Director 1, he stated that he was not the attending physician and he does not know who the attending physician for Patients 1,2 7 and 9. He stated since this patient was admitted to their hospice service, he is now the patient's attending physician, that he signed the referral attending physician section because no one will sign it.. He further stated that he did not do a face-to-face encounter with Patient 1 during her admission to hospice service but he determines the patient is eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. On 1/20/23, at 1 p.m., during an interview with the DPCSD (director of patient care services designee), she stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. A review of the policy "Admission Criteria and Process", indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination.

Based on observation, interview and record review, the hospice agency failed to ensure the medical director or physician designee assumed the responsibility for the medical component of the hospice's patient care program, that included conducting an assessment, reviewing, and verifying patient clinical information necessary for initial certification and recertification of terminal illness for seven of nine sampled patients (Patient 2, 3, 5, 6, 7, 8, and 10). These deficient practices resulted in the hospice medical director and/or the hospice attending physicians certifying patients for hospice care, without reviewing and verifying patients clinical information. --- 3. A review of Patient 3s admission record indicated the patient was admitted to the HA on 10/17/22, with a primary diagnosis of hypertensive heart disease without failure ( is a long term condition that develops over many years in people who have high blood pressure) A review of Patient 3's Certificate of Terminal Illness (CTI), dated 10/17/22 to 1/14/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 3 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 2/15/23, at 11 a.m., a home visit was conducted at Patient 3's residence with RN 1. The patient was observed walking with steady gait, breathing normally with no exertion. When Patient 3 also stated that one of the staff from the hospice agency referred her to this hospice agency. Patient 3 stated she was on home health before and wants to be discharged from this hospice agency. 5. A review of Patient 5's clinical record indicated a start of care date (SOC) of 12/20/22, with diagnoses which included heart failure (A chronic condition in which the heart doesn't pump blood as well as it should). A review of Patient 5's CTI, dated 12/20/22 to 1/14/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 5 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis 6. A review of Patient 6s admission record indicated the patient was admitted to the HA on 12/20/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD- is a disease that damages the lungs in ways that make it hard to breathe). A review of Patient 6's CTI, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicated Patient 6 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis 8. A review of Patient 8s admission record indicated the patient was admitted to the HA on 9/22/22, with a primary diagnosis of chronic obstructive pulmonary disease (COPD- is a disease that damages the lungs in ways that make it hard to breathe). A review of Patient 8's CTI, dated 11/21/22 to 1/19/23 , Benefit period #7 indicated the Medical Director signed the attending physician referral section indicated Patient 8 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis 10. A review of Patient 10s admission record indicated the patient was admitted to the HA on 8/2/22, with a primary diagnosis of hypertensive heart disease ( is a long term condition that develops over many years in people who have high blood pressure). A review of Patient 10's CTI, dated 1/29/22 to 3/29/23, Benefit period #3 indicated the Medical Director signed the attending physician referral section indicated Patient 10 had a life expectancy of six months or less, if the terminal illness runs its normal course. There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis There was no documentation for laboratory, and imaging data, history and physicals, biopsy results that show evidence to support the terminal illness diagnosis On 2/17/23, at 1 p.m., during an interview with the DOND (director of nursing designee), DOND stated in order for a new patient to be admitted at their hospice service, there should be a referral from the patient's attending physician. On 2/17/23, at 2 p.m., during a phone interview with Medical Director 1, he stated that he was not the attending physician and he does not know who the attending physician for Patients 1,2,3, 5, 6, 7, 8, 9 and 10. He stated since this patient was admitted to their hospice service, he is now the patient's attending physician, that he signed the referral attending physician section because no one will sign it.. He further stated that he did not do a face to face encounter with Patient 1 during her admission to hospice service but he determines the patient is eligible for hospice services by reviewing of patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. A review of the policy "Admission Criteria and Process", indicated the patient must have a life-limiting illness with a life expectancy of six months or less as determined by the attending physician and hospice medical director, utilizing standard clinical prognosis criteria in the organization's intermediary local coverage determination. Emanuel Hospice Inc. will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. The patient's physician must order and approve the provision of hospice care, be willing to sign or have a representative who is willing to sign the death certificate, and be willing to discuss the patients resuscitation status with the patient's resuscitation status with the patient and family/caregiver. 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. A review of the HA's policy titled "Professional Services Agreement for Medical Director" revised October 2011, indicated to ensure qualified medical direction and consultation for the delivery of hospice services and programs. To demonstrate that the medical Director/hospice team physician has overall responsibility for patient care through documentation that demonstrates interaction/communication with the attending physician as necessary for appropriate medical care. Reviewing patient's medical eligibility for hospice services, in accordance with hospice program policies and procedures, establishing plan of care in conjunctions with attending physician and interdisciplinary group prior to providing care written certification of terminal illness. A review of Patient 7's face sheet indicated admission to hospice on 11/26/22, with primary diagnosis of chronic obstructive pulmonary disease ( a lung disease that block airflow and make it difficult to breathe). It was indicated in the face sheet that Physician 7 was the Referring/Attending/Patient's choice doctor. A review of Patient 7's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 11/26/22, indicated the Licensed Vocational Nurse (LVN) was to visit once per week and one visit as needed. The Registered Nurse (RN) was to visit once per two weeks. The spiritual counselor was to visit once per month, and the Medical social worker service was declined. A review of Patient 7's Certificate of Terminal Illness (CTI), dated 11/26/22 to 2/23/23, Benefit period #1 indicated the Medical Director signed the attending physician referral section indicating Patient 7 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 1/19/23, at 12 p.m., a home visit was conducted at Patient 7's residence with RN 7. The patient was observed walking with a steady gait without using any assistive device. When Patient 7 was asked who buys her groceries, she stated she goes out and takes the bus to buy groceries. She also stated that one of the staff from the hospice agency referred her to this hospice agency. On 1/19/23, at 2 p.m., during a phone interview with Physician 7, he stated Patient 7 was not his patient at all and the hospice agency was just using his name and credential. On 1/20/23, at 12 p.m., during an interview with Medical Director 1, he stated he was not the attending physician and he does not know who is the attending physician for Patient 7. He stated since this patient was admitted to their hospice service, he is now the patient's attending physician, and he signed the referral attending physician section because no one will sign it. He further stated that he did not do a face to face encounter with Patient 7 during her admission to hospice service but he determines the patient is eligible for hospice services by reviewing of the patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. On 1/20/23, at 1 p.m., during an interview with the DPCS (director of patient care services), he stated in order for a new patient to be admitted to their hospice service, there should be a referral from the patient's attending physician. i. A review of Patient 8's face sheet indicated admission to hospice on 10/2/22, with primary diagnosis of hypertensive chronic kidney disease (long standing disease of the kidneys leading to renal failure). It was indicated in the face sheet that Physician 8 was the Referring/Attending /Patient's choice doctor. A review of Patient 8's Plan of Care (POC)/Interdisciplinary Group (IDG), dated 10/2/22, indicated the Licensed Vocational Nurse (LVN) was to visit once per week and one visit as needed. The Registered Nurse (RN) was to visit once per two weeks. The spiritual counselor was to visit once per month, and the Medical social worker service was declined. A review of Patient 8's Certificate of Terminal Illness (CTI), dated 10/2/22 to 12/30/22, Benefit period #1 indicated the Medical Director signed the attending physician referral section which indicated Patient 8 had a life expectancy of six months or less, if the terminal illness runs its normal course. On 1/19/23, at 11 a.m., during a phone interview with Patient 8, she stated one of her friends referred her to the hospice service. She also stated she was not that sick that she will pass away in six months. On 1/19/23, at 3 p.m., during a phone interview with Physician 8, he stated that Patient 8 was his patient, but he did not refer her to hospice services. He also stated Patient 8 does not need hospice services at all. On 1/20/23, at 12 p.m., during an interview with Medical Director 1, he stated he was not the attending physician and he does not know who is the attending physician for Patient 8. He stated since this patient was admitted to their hospice service, he is now the patient's attending physician, and he signed the referral attending physician section because no one will sign it. He further stated that he did not do a face to face encounter with Patient 8 during her admission to hospice service, but he determines the patient is eligible for hospice services by reviewing of the patient's medical records provided by the hospital and assessment report given by the registered nurse upon their initial visit to the patient. On 1/20/23, at 1 p.m., during an interview with the DPCS (director of patient care services), he stated in order for a new patient to be admitted to their hospice service, there should be a referral from the patient's attending physician. A review of the agencys undated policy and procedure titled ";Physician Services – Medical Director," indicated the purpose of the policy and procedure is to ensure qualified medical direction and consultation for the delivery of hospice services and programs. The policy and procedure further indicated the purpose of the policy and procedure is to demonstrate that the medical director/hospice team physician has overall responsibility for patient care through documentation that demonstrates interaction/communication with attending physician as necessary for appropriate medical care.

Based on interview and record review, the hospice agency failed to obtain a written agreement with the SNF (skilled nursing facility) that specifies the provision of hospice services in the facility. The deficient practice has the potential to affect the continuity of hospice services as identified in the patients' plan of care. --- On 2/14/23, at 10 a.m., a re-certification survey was conducted at the hospice agency. At 11 a.m., during an interview with the DPCSD (director of patient care services), when asked if the hospice agency has any contract agreement with the SNF facility, DPCSD stated the agency has no contract at this time and further stated that she could not find any documentation of a contract agreement with the SNF that specifies the provision of hospice services.