Every finding on record at Eros Hospice Inc

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 three of five sampled patients (Patients 5, Patient 6, and Patient 7) 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 Patient 5, Patient 6, and Patient 7. 2. The Director of Patient Care Services (DPCS) did not oversee the completion of initial comprehensive assessment of patients within 48 hours of admission. This deficient practice had the potential to cause delay of patient care, uncontrolled patient pain, and undetected signs of physical, emotional, and spiritual needs when transitioning to final stages of dying process. --- On 10/13/2023 at 4:07 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 agency's Administrator (ADM) for the agency's failure to conduct the initial assessments for Patients 5, 6 and 7 within 48 hours of admission. On 10/13/2023 at 4:20 p.m., the survey team completed the survey tasks, and exited the agency with the IJ situation not removed. a. During a review of Patient 5s Personal Information, Patient 5s Personal Information indicated a start of care (SOC) date of 9/14/2022, with a diagnosis of hypertensive heart disease (heart problems due to high blood pressure that is present over a long time) without heart failure (a condition that develops when the heart does not pump enough blood for the body's needs). During a concurrent interview and record review on 10/11/2023 at 2:15 p.m. with the Administrator (ADM), Patient 5s initial comprehensive assessment was reviewed. The ADM stated, ";We dont have Patient 5s initial and comprehensive assessment, in Patient 5s file." The ADM stated, ";The nurses did not submit any of these documents yet, usually we give them like 3 weeks to submit since they have so many patients." The ADM stated, ";The nurses just communicate with each other and do the home visits" without initial assessment and plan of care. The ADM stated the nurse that conducted an initial assessment was Licensed Vocational Nurse (LVN 1) and not a Registered Nurse (RN). During a telephone interview on 10/11/2023 at 2:45 p.m., Patient 5 stated, ";I am not familiar with any hospice agency, I never signed up for hospice service, I never got any documents, and I never signed any papers." Patient 5 stated, ";Nobody has ever visited me, no doctor, no nurse from a hospice agency. I'm very healthy I don't have any issues to be on hospice, I only have diabetes." Patient 5 stated, ";My primary care physician wouldn't refer me to be on hospice because Im not dying. I don't know how this agency got my information." During a telephone interview on 10/11/2023 at 6:21 p.m. with RN 1, RN 1 stated, ";I have a vague recollection of doing the initial assessment for Patient 5. I have so many patients and work different places, so I cant remember." RN 1 stated ";I usually try to do the initial assessment by the end of the week, but I havent been able to. I just communicate with the LVN to do the visits and what needs to be done." During a joint home visit with LVN 1 on 10/12/2023 at 10:15 a.m. at Patient 5s residence, and an interview with Patient 5, Patient 5 stated, he called the number that was provided to him from the group that was offering free phone and LVN 1 (pointing to LVN 1) answered the phone. Patient 5 stated LVN visited him but LVN 1 did not explain about the hospice services. During an interview with LVN 1 on the same date and time (10/12/2023 at 10:15 a.m.), LVN 1 stated, Patient 5 was not her regular patient, and the agency told her Patient 5 needed an emergency visit and she conducted home visit (could not remember the date) but she did not write the notes regarding the home visit. During a telephone interview on 10/13/2023, at 10:43 am, with Patient 5 in his native language (Spanish), Patient 5 stated, he did not know he was enrolled in hospice until yesterday, 10/12/2023. Patient 5 stated he could not remember the date when he inquired about a free cell phone service and spoke to someone (does not remember the name) and that person provided him with telephone number of LVN 1. Patient 5 stated, LVN 1 told him he would receive free supplies as wipes, walker, recliner, cream, body wash, walking cane, and other supplies that he has to return back and did not explain the hospice services. Patient 5 stated that no nurse has seen him nor assessing him until yesterday 10/12/2023, the first time a nurse (from the hospice agency) went to his house to visit. b. A review of Patient 6's ";Personal Information" indicated Patient 6 was admitted to hospice agency on 9/15/2023 with a primary diagnosis of hypertensive heart disease without heart failure. A review of Patient 6s ";Comprehensive Nursing Assessment," dated 9/15/2023, indicated the initial comprehensive nursing assessment was left blank, except for patients name, visit date, time in, time out, and medical record number. During interview with Patient 6 on 10/13/2023 at 11:02 a.m., Patient 6 stated the hospice agency nurse or a physician did not come to his home for a home visit. During a concurrent interview and record review on 10/11/2023, at 3:45 p.m., the Administrator (ADM), reviewed Patient 6s record titled, ";Comprehensive Nursing Assessment", dated 9/15/2023. The ADM stated the nurse had not complete the initial comprehensive assessment. The ADM stated, ";The nurses have three weeks to complete the initial comprehensive assessment. The ADM stated, ";I know theyre busy, so I give them 3 weeks." During a telephone interview on 10/13/2023 at 11:02 p.m., with Patient 6 in his native language (Spanish) , Patient 6 stated he went to a market (unidentified, and could not remember the date and time) and he requested a free cellphone. Patient 6 stated LVN 1 called him and told him he and his family member would receive free supplies such as water, diapers, chair, and other supplies that he could not remember from a ";programa," which translates as program. Patient 6 stated he did not know he was enrolled in hospice, since he does not have a terminal illness. Patient 6 stated no nurse came to his home to visit or assess him. Patient 6 denied signing any papers from the hospice. Patient 6 stated he sent to LVN 1 his and his family member pictures of their Medicare and medical card via text as requested by LVN 1 (unknown date). Patient 6 stated he had not seen a nurse, had not received home visits and had not seen a physician from the hospice agency. c. A review of Patient 7's ";Personal Information" indicated Patient 7 was admitted to hospice agency on 8/26/2023 with a primary diagnosis of heart failure (a condition that develops when the heart does not pump enough blood for the body's needs), unspecified. A review of Patient 7s ";Comprehensive Nursing Assessment," dated 10/12/2023, indicated the comprehensive nursing assessment was left blank, except for patients name, visit date, time in, time out, and medical record number. The visit date on the document was 10/12/2023. During a concurrent interview and record review on 10/12/2023, at 3:35 p.m., with the ADM, Patient 7s ";Comprehensive Nursing Assessment", dated 10/12/2023 was reviewed. The ADM stated Patient 7s initial comprehensive assessment was not done. During a telephone interview on 10/13/2023 at 2:40 p.m., with Patient 7 in her native language (Spanish), Patient 7 stated she received Physical Therapy (PT, improve a person's range of movement and quality of life and prevent further injury or disability) services before the HA program. Patient 7 stated the PT from outside (another agency) was stopped about a month ago and it was during the same time she was enrolled in the HA program. Patient 7 stated she has right arm pain 10 over 10 (10/10, a numeric pain scale with zero as no pain and 10 over 10 as the worst pain you have ever experienced) and the PT was helpful. Patient 7 stated she is not dying and she has her own Primary Care Physician (PCP). Patient 7 stated she needed medication for pain. Patient 7 stated no nurses have visited her and she had not received pain management from the HA. During a telephone interview on 10/13/2023 at 3:00 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated the initial assessment for Patients 5, 6, and 7 should have been done within 24-48 hours of admission. The DPCS stated the plan of care would not be generated without a complete initial assessment. DPCS stated for not doing the initial comprehensive assessment within 48 hours could cause patients harm because theres no care being provided to the patients. DPCS stated the necessary care (in general) was not provided to Patient 5, Patient 6, and Patient 7. A review of the agencys policy, titled ";Initial Assessment," revised November 2021, indicated that an initial assessment would be performed by a registered nurse within 48 hours after election of hospice care unless otherwise specified by the physician, patient, or representative to be completed in less than 48 hours. The policy also indicated that the admitting registered nurse used an assessment scale/rating tool to assess for problems and to establish a baseline status of each symptom rated; items assessed may include, but are not limited to the following: A. Pain assessment B. Vital signs C. Fatigue, drowsiness D. Nausea, appetite E. Depression, anxiety F. Shortness of breath G. Well-being, spiritual needs

Based on interview and record review, the hospice agency (HA) failed to ensure the patients comprehensive assessment (describes in detail a patient's medical, physical, and psychosocial condition and needs) were completed within five days after the election of hospice care for four of 5 sampled patients (Patients 5, 6, 7, and 8). This deficient practice had the potential to cause patient harm or injury and the delay of necessary services required in the patient care. --- Findings: b. A review of Patient 6's ";Personal Information" indicated Patient 6 was admitted on 9/15/23 with a primary diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition that develops when the heart does not pump enough blood for the body's needs). A review of Patient 6s ";Comprehensive Nursing Assessment," dated 9/15/23, indicated that the comprehensive nursing assessment was left blank, except for patients name, visit date, time in, time out, and medical record number. The form did not have the name of the Registered Nurse (RN) who was supposed to complete the comprehensive assessment. The form was also not signed by the RN who was supposed to complete the comprehensive assessment. A review of Patient 6s ";History of Psychosocial Assessment," indicated that no psychosocial assessment was completed since start of care. A review of Patient 6s POC Summary, indicated the POC Summary was left blank, except for patients name and the Medical Directors name. During interview with Patient 6 on 10/13/23 at 11:02 a.m., Patient 6 stated he had not seen a nurse or a physician from the hospice agency. c. A review of Patient 7's ";Personal Information" indicated Patient 6 was admitted on 8/26/23 with a primary diagnosis of heart failure (a condition that develops when the heart does not pump enough blood for the body's needs), unspecified. A review of Patient 7s ";Comprehensive Nursing Assessment," dated 10/12/23, indicated that the comprehensive nursing assessment was left blank, except for patients name, visit date, time in, time out, and medical record number. The form did not have the name of the Registered Nurse (RN) who was supposed to complete the comprehensive assessment. The form was also not signed by the RN who was supposed to complete the comprehensive assessment. During interview with Patient 8, the spouse of Patient 7, on 10/13/23 at 2:40 p.m., Patient 8 stated that both of them had not have a home visit by anyone from the hospice agency. Patient 8 stated no nursing assessments were ever done by a staff of the hospice agency. Patient 8 stated his wife (Patient 7) had 9/10 and 10/10 pain to her right arm and it was chronic and was only taking Tylenol and was not effective. A review of Patient 7s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form, dated 9/15/23, indicated the POC/IDG was left blank. The ";IDG Discussion" section for nursing, spiritual, psychosocial, and other/physician were not filled out. The spaces for MD signature, MSW signature, RN signature, and Chaplain signature did not have any signatures. During a telephone interview with the Director of Patient Care Services (DPCS) on 10/13/23 at 3 p.m., the DPCS stated the initial comprehensive assessment needed to be done in twenty four to forty eight hours upon admission. When asked why it was important to have a complete initial assessment within forty eight hours, the DPCS stated that the plan of care could not be generated without a complete initial assessment. The DPCS stated that not conducting the initial comprehensive assessment within forty eight hours could cause the patient harm, because it meant no care was being provided to patient. A review of the agency's policy, titled "Comprehensive Assessment, revised November 2021, indicated that a comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. The policy also indicated that during the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patient's clinical record, including at least the following information, as relevant: A. An assessment of pain, including the origin, location, duration, severity, and relief measures. a. During a review of Patient 5s Face sheet, indicated a start of care (SOC) date of 9/14/2022, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During a review of Patient 5s "Physician's Certification for Hospice Benefit", (CTI), for the first 90 day period from 9/19/2023 to 12/17/2023, indicated a terminal diagnosis of hypertensive heart disease without heart failure. There is no Medical Director (MD) narrative note on CTI. During a review of Patient 5s electronic medical record, the initial comprehensive assessment was blank. During a concurrent interview and record review on 10/11/2023 at 2:15 p.m. with the Administrator (ADM), ADM stated, ";we dont have Patient 5s initial and comprehensive assessment, hospice consents, LCD, Plan of Care or IDG notes in the file. All we have in the electronic medical record is the CTI, the factsheet and the medication list. The nurses did not submit any of these documents yet, Usually we give them like 3 weeks to submit since they have so many patients." When asked how the plan of care is developed if the initial comprehensive assessment is not in the system for the nurses to know what needs to be done during the home visits without all the documents in the file, ADM stated, ";the nurses just communicate with each other and do the home visits." When asked if they have a hard file with the patient consents in there, the ADM stated, ";no we dont have the consent for Patient 5 in the office, the nurse that did the initial assessment has it." When asked who the nurse that did the initial assessment for Patient 5 is, she stated ";Registered Nurse 1 (RN 1)." When asked who the Licensed Vocational Nurse 1 (LVN 1) is for Patient 5, she stated, ";LVN 1." During a phone interview on 10/11/2023 at 2:45 p.m. in Spanish with Patient 5, when asked if patient is currently under the care of Eros Hospice, Patient 5 stated, ";I am not familiar with any Hospice agency, I never signed up for Hospice. I recently went to those places where there are people that sign you up to get a free phone. I spoke to a lady and she gave me a phone number to call for other government benefits, and I called. I got some supplies but I never signed up for hospice. I never got any documents, I never signed any papers. Nobody has ever visited me, no doctor, no nurse from a hospice. I'm very healthy I don't have any issues to be on Hospice, I only have diabetes. I know what Hospice is. A couple of my friends had Hospice years ago and it's for patients that are going to die I'm not going to die." When asked if his primary care physician knows he's on Hospice or has ever referred him to be on Hospice. Patient stated, ";no like I said I'm not on Hospice my primary care physician wouldn't refer me to be on Hospice because Im not dying. I don't know how this agency got my information." When asked if its okay to visit him tomorrow at 9:30 am, he stated, ";yes of course." During a phone interview on 10/11/2023 at 6:21 p.m. with RN 1, when asked about Patient 5s initial comprehensive assessment, RN 1 stated, ";I have a vague recollection of doing the initial assessment for Patient 5. I have so many patients and work different places, and I go to school, so I cant remember." When asked how long after the initial assessment do they have to turn in the patient consents and the initial comprehensive assessment to the office, he stated ";I usually try to do it by the end of the week but I havent been able to." When asked how the plan of care is formulated if the initial comprehensive assessment is not in the system, or none of the other documents have been uploaded, he stated, ";I just communicate with the LVN to do the visits and what needs to be done. I need to look in my log to see what documents I have for this patient and I will send it to the office." During a joint home visit interview in Spanish with LVN 1 on 10/12/2023 at 10:15 a.m. at Patient 5 residence, when asked if Patient 5 knows what agency LVN 1 works for, Patient 5 stated, ";no, when I went to the those people that give free phones, there was someone there, I asked her if she knows of any other government agencies, and she gave me a number and said call this number and they will take care of you. I called the number and LVN 1 (pointing to LVN 1) answered the phone and came and visited me once." During a joint home visit interview in Spanish with the LVN 1, LVN 1 stated, ";this patient is not my regular patient, the agency told me they needed an emergency visit for Patient 5, and I came, this is the second time I am coming here." When asked if LVN 1 recalls what day the last visit was, LVN 1 stated, ";no I dont remember." When asked if LVN 1 wrote a note for the visit, LVN 1 stated, ";no I didnt." LVN 1 asked Patient 5 if anyone else from the agency has come to visit Patient 5, nurses or a doctor, Patient 5 stated, ";no." LVN 1 asked patient 5 if Patient 5 signed any documents to sign on to hospice, the patient stated, ";no". LVN 1 asked Patient 5 if Patient 5 received any supplies, Patient 5 stated, ";I received a walker, a toilet extension, wipes, a body wash, and vitamins, thats it." During a joint home visit interview in Spanish on 10/12/2023 at 10:30 a.m. with the Patient 5, when asked if Patient 5 sees a primary care physician and if Patient 5s primary care physician referred Patient 5 to hospice, Patient 5 stated, ";I see my primary care physician every three months. He never referred me to hospice. I dont have any issued other than diabetes. I know what hospice is. One of my friends had cancer a few years ago and he had hospice. It was a nice service, the nurses would come check on him and they would send a priest to the house. I dont have a condition like that. I only have diabetes." When asked if anyone else has gone to visit Patient 5 from a hospice other than LVN 1, or asked him to sign paperwork to sign up for hospice, including a nurse or a doctor, Patient 5 stated ";no, no one else has come to my house. I havent talked to anyone else or signed any papers." During a Spanish telephone interview on 10/13/2023, at 10:43 am, with Patient 5, Patient 5 stated he did not accept to be in Hospice. Patient 5 stated he did not know he was enrolled in Hospice until yesterday 10/12/2023. He does not remember the date when he inquired about a free cell phone service and spoke to someone (does not remember the name) and that person provided him with LVN 1 telephone #. Patient 5 stated he then called LVN 1 and LVN 1 told him he would receive free supplies as wipes, walker, recliner, cream, body wash, walking cane, and other supplies that he has to return back and did not explain the Hospice services. Patient 5 stated he remembers signing papers but does not remember the date when a man (unidentified) went to his house and had him sign the forms in English. He stated he does not know what he signed as the forms were in English and he only understands a little bit of English and prefers Spanish. He stated that no nurse has seen him nor assessing him until yesterday 10/12/2023, the first time a nurse went to his house to visit. Patient 5 stated he was confused because he does not have a terminal illness and wants to live many years (200 years) and that he only has diabetes and does not think diabetes is terminal. Patient 5 stated he has not seen nor heard from a Hospice Dr. d. A review of Patient 8s Patient Information Sheet indicated a Start of Care (SOC) of 8/28/2023 with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure with a chronic condition in which the heart doesn't pump blood as well as it should). A review of Patient 8s Certification of Terminal Illness (CTI), Certification #1: Certification Statement for Next 90-day period from 8/28/2023 to 11/25/2023 indicated Patient 8s primary diagnosis was hypertensive heart disease with heart failure. A review of Patient 8s electronic medical record, the comprehensive assessment section was blank. During a telephone interview on 10/13/2023 at 2:40 p.m. in Spanish with Patient 8, the husband of Patient 7. Patient 8 stated he does not remember when him and his wife were enrolled in a ";program," that offered them free supplies. Patient 8 stated his friend (Friend 1 ) referred him and his wife to LVN 1 who was friends with LVN 1 and the one who enrolled them to receive supplies. Patient 8 stated he and his wife received the following about a month ago for the first time and again about a week ago: Walker Diapers Gloves Shampoo COVID tests Wipes Patient 8 stated he feels bad because he does not need all the supplies and was thinking of giving the supplies to his church. Patient 8 stated he does not have a terminal illness and does not know what hospice is. Patient 8 stated no one has ever visited him or his wife. Patient stated no nursing assessments were ever done and does not recall signing any HA forms. Patient 8 stated his wife (Patient 7) had 9/10 and 10/10 pain to her right arm and it was chronic and was only taking Tylenol and was not effective. Patient 8 stated he feels bad not knowing about the HA program, stated he does not have a HA binder at home for him or for his wife. During a phone interview on 10/13/2023 at 3:00 p.m. with Director of Patient Care Services (DPCS), When asked about Patient 5, Patient 6, and Patient 7, DPCS stated the initial assessment should have been done within 24-48 hours of admission. When asked why is it important to have a complete initial assessment, DPCS stated because the plan of care can not be generated with out a complete initial assessment. When asked if there is no initial assessment can there be harm to the patient. DPCS stated yes because care is not being provided to the patient. When asked so how is care being provided for Patient 5, Patient 6, and Patient 7, DPCS stated the nurse who goes to see them for home visits should do their own assessments and reporting any unusual occurrences to the DCPS or MD. When asked if DPCS participated in any IDG meetings for Patient 5, Patient 6, Patient 7 and Patient 8 DPCS stated she has only received report for Patient 5 from LVN 2 regarding pain. When asked if she received any reports for Patient 5, Patient 6, Patient 7 and Patient 8, DPCS stated she did receive a report for PT5 from LVN 2 regarding pain. During a concurrent interview and record review on 10/13/2023 at 3:30 p.m. with the ADM, when asked to provide Patient 8s hospice election consents, ADM stated, its not in his electronic medical record, and did not provide any consents for Patient 8. Initial comprehensive assessment, IDG notes, LCD, and nurse visit notes blank. A review of the hospice agencys policy and procedure titled ";Comprehensive Assessment" revised November 2021, the policy indicated, ";a comprehensive patient assessment will be performed by the interdisciplinary group no later than five calendar days after the election of Hospice care in consultation with attending physician. 1. during the comprehensive patient assessment, all baseline data and other relevant information will be documented, through interview and observation, in the patients clinical record, including at least the following information, as relevant: A. and assessment of pain, including the origin, location, duration, severity, and relief measures..., C. Major and condition causing admission (including the presence or lack of objective data and subjective complaints), D. alleviating and exacerbating factors for physical symptoms...F. I'm assessment of the patients response to palliative treatment. G. a physical assessment, including blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patients terminal illness H. imminence of death...K. patients past and present medical and psychosocial history including pertinent diagnosis and any comorbid conditions, L. name and address of the patients attending physician T. An assessment of the patients and family/caregiver spiritual orientation, including, as appropriate, any involvement in a religious group such as a church or synagogue or a support group such as Alcoholics Anonymous and spiritual concerns or needs such as despair, suffering, guilt, etc..." The policy further indicated, ";2. The assessment should determine: A. probable prognosis of six months or less B. patient problems and needs related to the terminal illness C. patient goals related to the terminal illness D. type of services, frequency, and duration needed to meet patient care needs...4. The clinical supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis. 5. the comprehensive assessment is updated by the interdisciplinary group S frequent as the patient's condition requires but at a minimum every 15 days."

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 meet the Condition of Participation (conditions that health care organizations must meet to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities] Programs) for Interdisciplinary group (IDG, a group of healthcare professionals from different disciplines caring for the patient), care planning, and coordination of services as follows: 1. The HA failed to ensure the IDG, and the Medical Director 1 (MD1) provided the care and services offered by the HA for four of five sampled patients (Patient 5, Patient 6, Patient 7, and Patient 8). (Refer to L539). 2. The HA filed to develop a plan of care to meet the needs of four of five sampled patients (Patient 5, Patient 6, Patient 7, and Patient 8). (Refer to L543). 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.

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, a group of healthcare professionals from different disciplines caring for the resident), and the Medical Director (MD1) provided the care and services offered by the HA for four of five sampled patients (Patient 5, Patient 6, Patient 7, and Patient 8). This deficient practice had the potential not to address the needs of Patient 5, Patient 6, Patient 7, and Patient 8 and to delay their care. --- c. During a review of Patient 6's Personal Information, Patient 6's Personal Information indicated Patient 6 was admitted on 9/15/2023 with a primary diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition that develops when the heart does not pump enough blood for the body's needs). During a review of Patient 6s Comprehensive Nursing Assessment, the Comprehensive Nursing Assessment, dated 9/15/2023, indicated the comprehensive nursing assessment was blank, except for patients name, visit date, time in, time out, and medical record number. The form did not have the name of the Registered Nurse (RN) who was supposed to complete the comprehensive assessment. The form was also not signed by the RN who was supposed to complete the comprehensive assessment. During a review of Patient 6s undated History of Psychosocial Assessment, the History of Psychosocial Assessment indicated that no psychosocial assessment was completed since start of care. During a review of Patient 6s undated Plan of Care (POC) Summary, the POC Summary indicated it was blank, except for the patients name and the Medical Directors name. During a concurrent interview and record review, on 10/11/2023, at 3:45 p.m., with the ADM, Patient 6's Plan of Care/IDG records were reviewed. The ADM stated there were no assessments and no IDG notes for Patient 6. d. During a review of Patient 7's Personal Information, the Personal Information indicated Patient 7 was admitted on 8/26/2023 with a primary diagnosis of heart failure (a condition that develops when the heart does not pump enough blood for the body's needs), unspecified. A review of Patient 7s undated POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form, dated 9/15/2023, indicated the POC/IDG was blank. The ";IDG Discussion" section for nursing, spiritual, psychosocial, and other/physician were not filled out. The spaces for MD signature, MSW signature, RN signature, and Chaplain signature did not have any signatures. During a concurrent interview and record review, on 10/11/2023, at 3:45 p.m., with the ADM, Patient 7's Plan of Care/IDG records were reviewed. The ADM stated there were no assessments and no IDG notes for Patient 7. During a review of Patient 7s Comprehensive Nursing Assessment, dated 10/12/2023, the Comprehensive Nursing Assessment was blank, except for patients name, visit date, time in, time out, and medical record number. The form did not have the name of the Registered Nurse (RN) who was supposed to complete the comprehensive assessment. The form was also not signed by the RN who was supposed to complete the comprehensive assessment. During interview on 10/13/2023, at 2:40 p.m., Patient 7 stated she had 9/10 and 10/10 pain (0 means no pain and 10 means having the worst pain) to her right arm. Patient 7 stated she would take Tylenol (pain relief medication) and was not effective. Patient 7 stated she (Patient 7) and Patient 8 did not have a home visit by anyone from the HA. Patient 7 stated no nursing assessments were ever done by a staff of the HA. During a telephone interview on 10/13/2023, at 3 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she did not participate in any IDG meetings for Patient 5, Patient 6, Patient 7, and Patient 8. a. During a review of Patient 5s Face sheet, the Face Sheet indicated a start of care (SOC) date of 9/14/2023, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During a review of Patient 5s Physician's Certification for Hospice Benefit (CTI), dated for the first 90day period from 9/19/2023 to 12/17/2023, the Physician's Certification indicated a terminal diagnosis of hypertensive heart disease without heart failure. During a concurrent interview and record review, on 10/11/2023, at 2:15 p.m., with the Administrator (ADM), Patient 5s entire medical record was reviewed. The ADM stated the HA did not conduct Patient 5s initial and comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed to promote the hospice patient's well-being, comfort, and dignity throughout the dying process). The ADM stated the HA did not have the hospice consents and did not develop a Plan of Care for Patient 5. The ADM stated the plan of care needed to be developed for the HA staff (in general) to know the patients needs (in general) and what needed to be done during each home visit. The ADM stated there were no records for the IDG. During a telephone interview on 10/11/2023, at 2:45 p.m., with Patient 5, Patient 5 stated the HA staff did not visit him and stated he had a diagnosis of diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels). During a telephone interview on 10/13/2023, at 10:43 am, with Patient 5, Patient 5 stated he did not accept to be in Hospice. Patient 5 stated he did not know he was enrolled in Hospice until 10/12/2023. Patient 5 stated he did not remember the date when he inquired about a free cell phone service and spoke to someone (does not remember the name) provided him with Licensed Vocational Nurse 1 (LVN 1) telephone number. Patient 5 stated he then called LVN 1 and LVN 1 told him he would receive free supplies as wipes, walker, recliner, cream, body wash, walking cane, and other supplies and that LVN 1 did not explain the Hospice services. Patient 5 stated he remembered signing papers but did not remember the date when a man (unidentified) went to his house and had him sign the forms that he did not understand. Patient 5 stated that no nurse or other staff from the HA had seen him nor assessing him until 10/12/2023, the first time a nurse (LVN 1) went to his house to visit. Patient 5 stated he was confused because he did not have a terminal illness and wanted to live many years and that he only had diabetes and did not think diabetes was terminal. Patient 5 stated he had not seen nor heard from a Hospice Doctor. Patient 5 stated he was confused and overwhelmed about the HA. b. During a review of Patient 8s Patient Information Sheet, the Patient Information Sheet indicated a Start of Care (SOC) of 8/28/2023 with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure with a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 8s Certification of Terminal Illness (CTI), Certification Statement for Next 90-day period from 8/28/2023 to 11/25/2023 indicated Patient 8s primary diagnosis was hypertensive heart disease with heart failure. During a telephone interview on 10/13/2023, at 2:40 p.m., with Patient 8, Patient 8 stated he did not remember when him and Patient 7 (significant other) were enrolled in a ";program," that offered them free supplies. Patient 8 stated his friend (Friend 1) referred him and Patient 7 to LVN 1 who was friends with LVN 1 and the one who enrolled them to the HA to receive free supplies. Patient 8 stated he and Patient 7 received a walker (is a type of mobility aid that offers stability and support while walking), adult briefs (disposable underwear), gloves, shampoo, COVID (a respiratory illness that can spread from person to person) tests, and wipes. Patient 8 stated he felt bad because he did not need all the supplies and was thinking of giving the supplies to his church. Patient 8 stated he did not have a terminal illness and did not know what hospice was. Patient 8 stated no one form the HA had ever visited him or Patient 7. Patient stated no nursing assessments were ever done and did not recall signing any HA forms. Patient 8 stated he was concerned about Patient 7s uncontrolled pain to her right arm. Patient 8 stated Patient 7 would take Tylenol (pain relief medication) and was not effective. Patient 8 stated he did not know what to do regarding Patient 7s arm pain and felt bad about not knowing about the HA. During an attempted phone interview on 10/13/2023, at 3:28 p.m., with the HAs Medical Director 1 (MD1) with no success. During a concurrent interview and record review, on 10/13/2023, at 3:30 p.m., with the ADM, Patient 8s medical record was reviewed. The ADM stated there were no comprehensive assessment, plan of care, HA consent forms, and no IDG notes, no nursing and visit notes for Patient 8. During an interview on 10/13/2023, at 3:30 pm, with the ADM, the ADM stated the HA did not have the policies and procedures for plan of care and Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). During an attempted phone interview on 10/13/2023, at 3:32 p.m., with MD 1 office number, there was no answer, and the surveyor left a message to call back.

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 develop a plan of care to meet the needs of four of five sampled patients (Patient 5, Patient 6, Patient 7, and Patient 8). This deficient practice resulted in delayed care, uncontrolled pain, symptom management, and undetected sign of physical, emotional, spiritual needs for Patient 5, Patient 6, Patient 7, and Patient 8. --- c. During a review of Patient 6's Personal Information, Patient 6's Personal Information indicated Patient 6 was admitted on 9/15/2023 with a primary diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition that develops when the heart does not pump enough blood for the body's needs). During a review of Patient 6s Comprehensive Nursing Assessment, the Comprehensive Nursing Assessment, dated 9/15/2023, indicated the comprehensive nursing assessment was blank, except for patients name, visit date, time in, time out, and medical record number. The form did not have the name of the Registered Nurse (RN) who was supposed to complete the comprehensive assessment. The form was also not signed by the RN who was supposed to complete the comprehensive assessment. During a review of Patient 6s undated History of Psychosocial Assessment, the History of Psychosocial Assessment indicated that no psychosocial assessment was completed since start of care. During a review of Patient 6s Plan of Care (POC) Summary, the POC Summary indicated it was blank, except for the patients name and the Medical Directors name. During a concurrent interview and record review, on 10/11/2023, at 3:45 p.m., with the ADM, Patient 6's Plan of Care/IDG records were reviewed. The ADM stated there were no assessments and no IDG notes for Patient 6. d. During a review of Patient 7's Personal Information, the Personal Information indicated Patient 7 was admitted on 8/26/2023 with a primary diagnosis of heart failure (a condition that develops when the heart does not pump enough blood for the body's needs), unspecified. A review of Patient 7s POC (Plan of Care)/IDG (Interdisciplinary Group- a team responsible for the holistic care of the hospice beneficiary) form, dated 9/15/2023, indicated the POC/IDG was blank. The ";IDG Discussion" section for nursing, spiritual, psychosocial, and other/physician were not filled out. The spaces for MD signature, MSW signature, RN signature, and Chaplain signature did not have any signatures. During a concurrent interview and record review, on 10/11/2023, at 3:45 p.m., with the ADM, Patient 7's Plan of Care/IDG records were reviewed. The ADM stated there were no assessments and no IDG notes for Patient 7. During a review of Patient 7s Comprehensive Nursing Assessment, dated 10/12/23, the Comprehensive Nursing Assessment was blank, except for patients name, visit date, time in, time out, and medical record number. The form did not have the name of the Registered Nurse (RN) who was supposed to complete the comprehensive assessment. The form was also not signed by the RN who was supposed to complete the comprehensive assessment. During interview on 10/13/2023, at 2:40 p.m., Patient 7 stated she had 9/10 and 10/10 pain (0 means no pain and 10 means having the worst pain) to her right arm. Patient 7 stated she would take Tylenol (pain relief medication) and was not effective. Patient 7 stated she (Patient 7) and Patient 8 did not have a home visit by anyone from the HA. Patient 7 stated no nursing assessments were ever done by a staff of the HA. During a telephone interview on 10/13/2023, at 3 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she did not participate in any IDG meetings for Patient 5, Patient 6, Patient 7, and Patient 8. a. During a review of Patient 5s Face sheet, the Face Sheet indicated a start of care (SOC) date of 9/14/2023, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During a review of Patient 5s Physician's Certification for Hospice Benefit (CTI), dated for the first 90day period from 9/19/2023 to 12/17/2023, the Physician's Certification indicated a terminal diagnosis of hypertensive heart disease without heart failure. During a concurrent interview and record review, on 10/11/2023, at 2:15 p.m., with the Administrator (ADM), Patient 5s entire medical record was reviewed. The ADM stated the HA did not conduct Patient 5s initial and comprehensive assessment (an assessment to identify the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that must be addressed to promote the hospice patient's well-being, comfort, and dignity throughout the dying process). The ADM stated the HA did not have the hospice consents and did not develop a Plan of Care for Patient 5. The ADM stated the plan of care needed to be developed for the HA staff (in general) to know the patients needs (in general) and what needed to be done during each home visit. During a telephone interview on 10/11/2023, at 2:45 p.m., with Patient 5, Patient 5 stated the HA staff did not visit him and stated he had a diagnosis of diabetes (a medical condition characterized by the body's inability to regulate blood sugar levels). During a telephone interview on 10/13/2023, at 10:43 am, with Patient 5, Patient 5 stated he did not accept to be in Hospice. Patient 5 stated he did not know he was enrolled in Hospice until 10/12/2023. Patient 5 stated he did not remember the date when he inquired about a free cell phone service and spoke to someone (does not remember the name) and that person provided him with Licensed Vocational Nurse 1 (LVN 1) telephone number. Patient 5 stated he then called LVN 1 and LVN 1 told him he would receive free supplies as wipes, walker (is a type of mobility aid that offers stability and support while walking), recliner, cream, body wash, walking cane, and other supplies that he had to return and did not explain the Hospice services. Patient 5 stated he remembered signing papers but did not remember the date when a man (unidentified) went to his house and had him sign the forms that he did not understand. Patient 5 stated that no nurse had seen him nor assessing him until 10/12/2023, the first time a nurse went to his house to visit. Patient 5 stated he was confused because he did not have a terminal illness and wanted to live many years and that he only had diabetes and did not think diabetes was terminal. Patient 5 stated he had not seen nor heard from a Hospice Doctor. Patient 5 stated he was confused and overwhelmed about the HA. b. During a review of Patient 8s Patient Information Sheet, the Patient Information Sheet indicated a Start of Care (SOC) of 8/28/2023 with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure with a chronic condition in which the heart does not pump blood as well as it should). During a review of Patient 8s Certification of Terminal Illness (CTI), Certification Statement for Next 90-day period from 8/28/2023 to 11/25/2023 indicated Patient 8s primary diagnosis was hypertensive heart disease with heart failure. During a telephone interview on 10/13/2023, at 2:40 p.m., with Patient 8, Patient 8 stated he did not remember when him and Patient 7 (significant other) were enrolled in a ";program," that offered them free supplies. Patient 8 stated his friend (Friend 1) referred him and Patient 7 to LVN 1 who was friends with LVN 1 and the one who enrolled them to the HA to receive free supplies. Patient 8 stated he and Patient 7 received a walker, adult briefs (disposable underwear), gloves, shampoo, COVID (a respiratory illness that can spread from person to person) tests, and wipes. Patient 8 stated he felt bad because he did not need all the supplies and was thinking of giving the supplies to his church. Patient 8 stated he did not have a terminal illness and did not know what hospice was. Patient 8 stated no one has ever visited him or Patient 7. Patient stated no nursing assessments were ever done and did not recall signing any HA forms. Patient 8 stated he was concerned about Patient 7s uncontrolled pain to her right arm. Patient 8 stated Patient 7 would take Tylenol (pain relief medication and was not effective. Patient 8 stated he did not know what to do regarding Patient 7s arm pain and felt bad about not knowing about the HA. During an attempted phone interview on 10/13/2023, at 3:28 p.m., with the HAs Medical Director 1 (MD 1) with no success. During a concurrent interview and record review, on 10/13/2023, at 3:30 p.m., with the ADM, Patient 8s medical record was reviewed. The ADM stated there were no comprehensive assessment, no plan of care, no HA consent forms, and no nursing visit notes for Patient 8. During an interview on 10/13/2023, at 3:30 pm, the ADM stated the HA did not have the policies and procedures for plan of care and Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities). During an attempted phone interview on 10/13/2023, at 3:32 p.m., with MD office number, there was no answer, and the surveyor left a message to call back.

Based on interview and record review, the hospice agency (HA) failed to ensure that it had a qualified administrator who is responsible for the day-to-day operation of the HA. This deficient practice had the potential to result in the agency operating with no adequate oversight from the administrator to comply with the state and/or federal regulations. --- On 10/13/23, a review of the HA employee files was conducted. The employee record for the Administrator (ADM) indicated that the ADM did not have the necessary education or credentials for a hospice administrator. During interview with the ADM on 10/13/23 at 1:40 p.m., when ADM was asked to provide her credentials that qualified her to act as a hospice administrator, the ADM stated, ";I think I have it in a folder." The ADM was not able to provide documented evidence of her qualifications until the end of the survey. When asked about the importance of having qualifications as a hospice administrator, the ADM stated, ";To make sure the administrator can operate the hospice agency."

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation for Medical Director was met as evidenced by: The hospice agency failed to ensure the medical director and/or physician designee (who is a hospice employee or under the contract with the hospice) reviewed patients clinical information to determine hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care criteria is met for four out of five sampled patients (Patient 5, Patient 6, Patient 7, and Patient 8). (Refer to L 667). 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 were provided to the patients certified to receive hospice services. --- Please refer to L667.

Based on interview, observation, and record review, the hospice agency (HA) failed to ensure the Medical Director conducted an accurate assessment, review, and verification the patients clinical information and current health condition, necessary to support the Certification of Terminal Illness (CTI, a hospice physician narrative brief summary, a brief designed to explain clinical findings that support a life expectancy of six months or less), to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care and services, for four out of five sampled patients (Patient 5, Patient 6, Patient 7, and Patient 8). The Medical Director certified patients for hospice care without documentation to support diagnosis of terminal illness. This deficient practice resulted in patients being admitted for hospice care with no documented evidence of patients' written clinical information was being reviewed and evaluated by the Medical Director and/or physician designee to support their diagnoses of terminal illness. --- b. A review of Patient 6's ";Personal Information" indicated Patient 6 was admitted on 9/15/23 with a primary diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition that develops when the heart does not pump enough blood for the body's needs). A review of Patient 6's ";Physicians Certification for Hospice Benefit", dated 9/15/23 to 12/13/23, benefit period #1, indicated Patient 6 had a life expectancy of six months or less, if the terminal illness ran its normal course and was eligible for hospice services under routine level of care, signed by the Medical Director (MD 1). The documents indicated that verbal authorization from the MD was obtained by Registered Nurse 1 (RN 1). There was no narrative written by MD 1 in the Certification of Terminal Illness (CTI) that summarized Patient 6s condition. A review of Patient 6s "LCD Hospice Eligibility Determination (Local Coverage Determination, guidelines used by hospice providers to determine eligibility of beneficiaries for hospice benefits)," indicated that Patient 6 did not qualify per LCD guidelines. The entire document was left blank, except for patients name and medical record number. A review of Patient 6s ";Comprehensive Nursing Assessment," dated 9/15/23, indicated that the comprehensive nursing assessment was not completed. During interview with Patient 6 on 10/13/23 at 11:02 a.m., Patient 6, who only spoke Spanish, stated he never signed any papers from the hospice agency. Patient 6 also stated he did not know he was enrolled in hospice, and he did not have a terminal illness. Patient 6 stated he was healthy for the most part and did not require nursing services. Patient 6 stated he was confused about the hospice program. Patient 6 stated he had not seen a nurse or a physician from the hospice agency. c. A review of Patient 7's ";Personal Information" indicated Patient 6 was admitted on 8/26/23 with a primary diagnosis of heart failure (a condition that develops when the heart does not pump enough blood for the body's needs), unspecified. A review of Patient 7's ";Physicians Certification for Hospice Benefit", dated 8/26/23 to 11/23/23, benefit period #1, indicated Patient 7 had a life expectancy of six months or less, if the terminal illness ran its normal course and was eligible for hospice services under routine level of care, signed by the Medical Director (MD 1). The documents indicated that verbal authorization from the MD was obtained by Registered Nurse 1 (RN 1). There was no narrative written by MD 1 in the Certification of Terminal Illness (CTI) that summarized Patient 7s condition. A review of Patient 7s "LCD Hospice Eligibility Determination (Local Coverage Determination, guidelines used by hospice providers to determine eligibility of beneficiaries for hospice benefits)," indicated that Patient 7 did not qualify per LCD guidelines. The entire document was left blank, except for patients name and medical record number. A review of Patient 7s ";Comprehensive Nursing Assessment," dated 8/26/23, indicated that the comprehensive nursing assessment was not completed. During interview with Patient 8, the spouse of Patient 7, on 10/13/23 at 2:40 p.m., Patient 8 stated that both of them had not have a home visit by anyone from the hospice agency. Patient 8 stated no nursing assessments were ever done by a staff of the hospice agency. Patient 8 stated his wife (Patient 7) had 9/10 and 10/10 pain to her right arm and it was chronic and was only taking Tylenol and was not effective. On 10/13/23 at 3:28 p.m., a request was made to speak to MD 1. An automated text message was subsequently received at 3:28 p.m. from MD 1s cellular telephone, stating, ";Sorry, I cant talk right now." On 10/13/23 at 3:29 p.m., a request to speak to MD 1 was made to MD 1s office. On 10/13/23 at 4:23 p.m., the office manager of MD 1 stated that MD 1 was out of town and would return the following week. A review of the HAs policy, titled ";Certification of Terminal Illness," revised November 2021, indicated that clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. a. During a review of Patient 5s Face sheet, indicated a start of care (SOC) date of 9/14/2022, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). A review of Patient 5's ";Physicians Certification for Hospice Benefit", dated 9/19/23 to 12/17/23, benefit period #1, indicated Patient 5 has a terminal diagnosis of hypertensive heart disease without heart failure and had a life expectancy of six months or less, if the terminal illness ran its normal course and was eligible for hospice services under routine level of care, signed by the Medical Director (MD 1). The documents indicated that verbal authorization from the MD was obtained by RN 1. There was no narrative written by MD 1 in the Certification of Terminal Illness (CTI) that summarized Patient 5s condition. A review of Patient 5s ";Comprehensive Nursing Assessment," indicated that the comprehensive nursing assessment was not completed. A review of Patient 5s electronic medical record, there were no supporting documents for terminal diagnosis. During a concurrent interview and record review on 10/11/2023 at 2:15 p.m. with the Administrator (ADM), ADM stated, ";we dont have Patient 5s initial and comprehensive assessment, hospice consents, LCD, Plan of Care or IDG notes in the file. All we have in the electronic medical record is the CTI, the factsheet and the medication list. The nurses did not submit any of these documents yet, Usually we give them like 3 weeks to submit since they have so many patients." When asked how the plan of care is developed if the initial comprehensive assessment is not in the system for the nurses to know what needs to be done during the home visits without all the documents in the file, ADM stated, ";the nurses just communicate with each other and do the home visits." When asked if they have a hard file with the patient consents in there, the ADM stated, ";no we dont have the consent for Patient 5 in the office, the nurse that did the initial assessment has it." When asked who the nurse that did the initial assessment for Patient 5 is, she stated ";Registered Nurse 1 (RN 1)." When asked who the Licensed Vocational Nurse 1 (LVN 1) is for Patient 5, she stated, ";LVN 1." During a phone interview on 10/11/2023 at 2:45 p.m. in Spanish with Patient 5, when asked if patient is currently under the care of Eros Hospice, Patient 5 stated, ";I am not familiar with any Hospice agency, I never signed up for Hospice. I recently went to those places where there are people that sign you up to get a free phone. I spoke to a lady and she gave me a phone number to call for other government benefits, and I called. I got some supplies but I never signed up for hospice. I never got any documents, I never signed any papers. Nobody has ever visited me, no doctor, no nurse from a hospice. I'm very healthy I don't have any issues to be on Hospice, I only have diabetes. I know what Hospice is. A couple of my friends had Hospice years ago and it's for patients that are going to die I'm not going to die." When asked if his primary care physician knows he's on Hospice or has ever referred him to be on Hospice. Patient stated, ";no like I said I'm not on Hospice my primary care physician wouldn't refer me to be on Hospice because Im not dying. I don't know how this agency got my information." When asked if its okay to visit him tomorrow at 9:30 am, he stated, ";yes of course." During a phone interview on 10/11/2023 at 6:21 p.m. with RN 1, when asked about Patient 5s initial comprehensive assessment, RN 1 stated, ";I have a vague recollection of doing the initial assessment for Patient 5. I have so many patients and work different places, and I go to school, so I cant remember." When asked how long after the initial assessment do they have to turn in the patient consents and the initial comprehensive assessment to the office, he stated ";I usually try to do it by the end of the week but I havent been able to." When asked how the plan of care is formulated if the initial comprehensive assessment is not in the system, or none of the other documents have been uploaded, he stated, ";I just communicate with the LVN to do the visits and what needs to be done. I need to look in my log to see what documents I have for this patient and I will send it to the office." During a joint home visit interview in Spanish with LVN 1 on 10/12/2023 at 10:15 a.m. at Patient 5 residence, when asked if Patient 5 knows what agency LVN 1 works for, Patient 5 stated, ";no, when I went to the those people that give free phones, there was someone there, I asked her if she knows of any other government agencies, and she gave me a number and said call this number and they will take care of you. I called the number and LVN 1 (pointing to LVN 1) answered the phone and came and visited me once." During a joint home visit interview in Spanish with the LVN 1, LVN 1 stated, ";this patient is not my regular patient, the agency told me they needed an emergency visit for Patient 5, and I came, this is the second time I am coming here." When asked if LVN 1 recalls what day the last visit was, LVN 1 stated, ";no I dont remember." When asked if LVN 1 wrote a note for the visit, LVN 1 stated, ";no I didnt." LVN 1 asked Patient 5 if anyone else from the agency has come to visit Patient 5, nurses or a doctor, Patient 5 stated, ";no." LVN 1 asked patient 5 if Patient 5 signed any documents to sign on to hospice, the patient stated, ";no". LVN 1 asked Patient 5 if Patient 5 received any supplies, Patient 5 stated, ";I received a walker, a toilet extension, wipes, a body wash, and vitamins, thats it." During a joint home visit interview in Spanish on 10/12/2023 at 10:30 a.m. with the Patient 5, when asked if Patient 5 sees a primary care physician and if Patient 5s primary care physician referred Patient 5 to hospice, Patient 5 stated, ";I see my primary care physician every three months. He never referred me to hospice. I dont have any issued other than diabetes. I know what hospice is. One of my friends had cancer a few years ago and he had hospice. It was a nice service, the nurses would come check on him and they would send a priest to the house. I dont have a condition like that. I only have diabetes." When asked if anyone else has gone to visit Patient 5 from a hospice other than LVN 1, or asked him to sign paperwork to sign up for hospice, including a nurse or a doctor, Patient 5 stated ";no, no one else has come to my house. I havent talked to anyone else or signed any papers." During a Spanish telephone interview on 10/13/2023, at 10:43 am, with Patient 5, Patient 5 stated he did not accept to be in Hospice. Patient 5 stated he did not know he was enrolled in Hospice until yesterday 10/12/2023. He does not remember the date when he inquired about a free cell phone service and spoke to someone (does not remember the name) and that person provided him with LVN 1 telephone #. Patient 5 stated he then called LVN 1 and LVN 1 told him he would receive free supplies as wipes, walker, recliner, cream, body wash, walking cane, and other supplies that he has to return back and did not explain the Hospice services. Patient 5 stated he remembers signing papers but does not remember the date when a man (unidentified) went to his house and had him sign the forms in English. He stated he does not know what he signed as the forms were in English and he only understands a little bit of English and prefers Spanish. He stated that no nurse has seen him nor assessing him until yesterday 10/12/2023, the first time a nurse went to his house to visit. Patient 5 stated he was confused because he does not have a terminal illness and wants to live many years (200 years) and that he only has diabetes and does not think diabetes is terminal. Patient 5 stated he has not seen nor heard from a Hospice Dr. d. A review of Patient 8s Patient Information Sheet indicated a Start of Care (SOC) of 8/28/2023 with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure with a chronic condition in which the heart doesn't pump blood as well as it should). A review of Patient 8's ";Physicians Certification for Hospice Benefit", dated 8/28/23 to 11/25/23, benefit period #1, indicated Patient 8 primary diagnosis was hypertensive heart disease with heart failure had a life expectancy of six months or less, if the terminal illness ran its normal course and was eligible for hospice services under routine level of care, signed by the Medical Director (MD 1). The documents indicated that verbal authorization from the MD was obtained by RN ). There was no narrative written by MD 1 in the Certification of Terminal Illness (CTI) that summarized Patient 8s condition. A review of Patient 8s "LCD Hospice Eligibility Determination (Local Coverage Determination, guidelines used by hospice providers to determine eligibility of beneficiaries for hospice benefits)," indicated that Patient 8 did not qualify per LCD guidelines. The entire document was left blank, except for patients name and medical record number. A review of Patient 8s electronic medical record, there were no supporting documents for terminal diagnosis. A review of Patient 8s electronic medical record, the comprehensive assessment blank. During a telephone interview on 10/13/2023 at 2:40 p.m. in Spanish with Patient 8, the husband of Patient 7. Patient 8 stated he does not remember when him and his wife were enrolled in a ";program," that offered them free supplies. Patient 8 stated his friend (Friend 1 ) referred him and his wife to LVN 1 who was friends with LVN 1 and the one who enrolled them to receive supplies. Patient 8 stated he and his wife received the following about a month ago for the first time and again about a week ago: Walker Diapers Gloves Shampoo COVID tests Wipes Patient 8 stated he feels bad because he does not need all the supplies and was thinking of giving the supplies to his church. Patient 8 stated he does not have a terminal illness and does not know what hospice is. Patient 8 stated no one has ever visited him or his wife. Patient stated no nursing assessments were ever done and does not recall signing any HA forms. Patient 8 stated his wife (Patient 7) had 9/10 and 10/10 pain to her right arm and it was chronic and was only taking Tylenol and was not effective. Patient 8 stated he feels bad not knowing about the HA program, stated he does not have a HA binder at home for him or for his wife. During an attempted phone interview on 10/13/2023 at 3:28 p.m. with MD on cell, no answer, left message to call back. At 3:31 p.m. automated text message received from the MD cell phone number ";Sorry. I cant talk now". During a concurrent interview and record review on 10/13/2023 at 3:30 p.m. with the ADM, when asked to provide Patient 8s hospice election consents, ADM stated, its not in his electronic medical record, and did not provide any consents for Patient 8. Initial comprehensive assessment, IDG notes, LCD, and nurse visit notes blank. During an attempted phone interview on 10/13/2023 at 3:32 p.m. with MD office number. No answer. A left message to call back.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation on Clinical Records was met as follows: 1. The HA failed to ensure that each patients record must include the initial plan of care, updated plan of care, initial assessment, comprehensive assessment, updated comprehensive assessments, and clinical notes, for four of five sampled patients (Patient 5, Patient 6, Patient 7, and Patient 8). (Refer to L672) 2. The HA failed to ensure the clinical records were completed and authenticated (genuine or real) by the author/HA staff (in general), for one of five sampled patients (Patient 5). (Refer to L679). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records are appropriately maintained and authenticated. --- Please refer to L672 and L679.

Based on interview and record review, the Hospice Agency (HA) failed to ensure that patients clinical record included the initial plan of care, updated plan of care, initial assessment, comprehensive assessment, and clinical notes, for four of five sampled patients (Patient 5, Patient 6, Patient 7, and Patient 8). This deficient practice had the potential to result in patients assessed needs not met and communication between health care providers involved in the patients care. --- c. A review of Patient 6's ";Personal Information" indicated Patient 6 was admitted on 9/15/23 with a primary diagnosis of hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time) without heart failure (a condition that develops when the heart does not pump enough blood for the body's needs). A review of Patient 6s ";Comprehensive Nursing Assessment," dated 9/15/23, indicated that the comprehensive nursing assessment was left blank, except for patients name, visit date, time in, time out, and medical record number. A review of Patient 6s ";History of Psychosocial Assessment," indicated that no psychosocial assessment was completed since start of care. A review of Patient 6s ";POC Summary," indicated the POC Summary was left blank, except for patients name and the Medical Directors name. A review of Patient 6s history of visit notes indicated there were no visit notes completed for Patient 6 since the start of care. d. A review of Patient 7's ";Personal Information" indicated Patient 7 was admitted on 8/26/23 with a primary diagnosis of heart failure (a condition that develops when the heart does not pump enough blood for the body's needs), unspecified. A review of Patient 7s ";Comprehensive Nursing Assessment," dated 10/12/23, indicated that the comprehensive nursing assessment was left blank, except for patients name, visit date, time in, time out, and medical record number. The form did not have the name of the Registered Nurse (RN) who was supposed to complete the comprehensive assessment. The form was also not signed by the RN who was supposed to complete the comprehensive assessment. A review of Patient 7s history of visit notes indicated there were no visit notes completed for Patient 7 since the start of care. During a concurrent interview and record review on 10/11/23, at 3:45 p.m., the Administrator (ADM), reviewed Patient 6s record titled, ";Comprehensive Nursing Assessment", dated 9/15/23. The record indicated that it was not completed. The ADM stated that the nurse had not completed the comprehensive assessment. When asked how soon the nurse had to complete the initial comprehensive assessment after admission, the ADM stated, ";The nurses have three weeks to complete the comprehensive assessment. I know theyre busy, so I give them 3 weeks." a. A review of Patient 5s Face sheet, indicated a start of care (SOC) date of 9/14/2022, with a primary diagnosis of hypertensive heart disease without heart failure (high blood pressure). During a review of Patient 5s "Physician's Certification for Hospice Benefit", (CTI), for the first 90 day period from 9/19/2023 to 12/17/2023, indicated a terminal diagnosis of hypertensive heart disease without heart failure. There is no Medical Director (MD) narrative note on Patient t's CTI. During a review of Patient 5s electronic medical record, the initial assessment, the comprehensive assessment, IDG/POC, LCD, nursing notes were blank. During a concurrent interview and record review on 10/11/2023 at 2:15 p.m. with the Administrator (ADM), ADM stated, ";we dont have Patient 5s initial and comprehensive assessment, hospice consents, LCD, Plan of Care or IDG notes in the file. All we have in the electronic medical record is the CTI, the factsheet and the medication list. The nurses did not submit any of these documents yet, Usually we give them like 3 weeks to submit since they have so many patients." When asked how the plan of care is developed if the initial comprehensive assessment is not in the system for the nurses to know what needs to be done during the home visits without all the documents in the file, ADM stated, ";the nurses just communicate with each other and do the home visits." When asked if they have a hard file with the patient consents in there, the ADM stated, ";no we dont have the consent for Patient 5 in the office, the nurse that did the initial assessment has it." When asked who the nurse that did the initial assessment for Patient 5 is, she stated ";Registered Nurse 1 (RN 1)." When asked who the Licensed Vocational Nurse 1 (LVN 1) is for Patient 5, she stated, ";LVN 1." During a phone interview on 10/11/2023 at 2:45 p.m. in the patient native language (Spanish) with Patient 5, when asked if patient is currently under the care of Eros Hospice, Patient 5 stated, ";I am not familiar with any Hospice agency, I never signed up for Hospice. I recently went to those places where there are people that sign you up to get a free phone. I spoke to a lady and she gave me a phone number to call for other government benefits, and I called. I got some supplies but I never signed up for hospice. I never got any documents, I never signed any papers. Nobody has ever visited me, no doctor, no nurse from a hospice. I'm very healthy I don't have any issues to be on Hospice, I only have diabetes. I know what Hospice is. A couple of my friends had Hospice years ago and it's for patients that are going to die I'm not going to die." When asked if his primary care physician knows he's on Hospice or has ever referred him to be on Hospice. Patient stated, ";no like I said I'm not on Hospice my primary care physician wouldn't refer me to be on Hospice because Im not dying. I don't know how this agency got my information." When asked if its okay to visit him tomorrow at 9:30 a.m., he stated, ";yes of course." During a phone interview on 10/11/2023 at 6:21 p.m. with RN 1, when asked about Patient 5s initial comprehensive assessment, RN 1 stated, ";I have a vague recollection of doing the initial assessment for Patient 5. I have so many patients and work different places, and I go to school, so I cant remember." When asked how long after the initial assessment do they have to turn in the patient consents and the initial comprehensive assessment to the office, he stated ";I usually try to do it by the end of the week but I havent been able to." When asked how the plan of care is formulated if the initial comprehensive assessment is not in the system, or none of the other documents have been uploaded, he stated, ";I just communicate with the LVN to do the visits and what needs to be done. I need to look in my log to see what documents I have for this patient and I will send it to the office." During a joint home visit interview in the patient native language (Spanish) with LVN 1 on 10/12/2023 at 10:15 a.m. at Patient 5 residence, when asked if Patient 5 knows what agency LVN 1 works for, Patient 5 stated, ";no, when I went to the those people that give free phones, there was someone there, I asked her if she knows of any other government agencies, and she gave me a number and said call this number and they will take care of you. I called the number and LVN 1 (pointing to LVN 1) answered the phone and came and visited me once." During a joint home visit interview in the patient native language (Spanish) with LVN 1, LVN 1 stated, ";this patient is not my regular patient, the agency told me they needed an emergency visit for Patient 5, and I came, this is the second time I am coming here." When asked if LVN 1 recalls what day the last visit was, LVN 1 stated, ";no I dont remember." When asked if LVN 1 wrote a note for the visit, LVN 1 stated, ";no I didnt." LVN 1 asked Patient 5 if anyone else from the agency has come to visit Patient 5, nurses or a doctor, Patient 5 stated, ";no." LVN 1 asked patient 5 if Patient 5 signed any documents to sign on to hospice, the patient stated, ";no". LVN 1 asked Patient 5 if Patient 5 received any supplies, Patient 5 stated, ";I received a walker, a toilet extension, wipes, a body wash, and vitamins, thats it." During a joint home visit interview in the patient native language (Spanish) on 10/12/2023 at 10:30 a.m. with Patient 5, when asked if Patient 5 sees a primary care physician and if Patient 5s primary care physician referred Patient 5 to hospice, Patient 5 stated, ";I see my primary care physician every three months. He never referred me to the hospice. I dont have any issued other than diabetes. I know what hospice is. One of my friends had cancer a few years ago and he had hospice. It was a nice service, the nurses would come check on him and they would send a priest to the house. I dont have a condition like that. I only have diabetes." When asked if anyone else has gone to visit Patient 5 from a hospice other than LVN 1, or asked him to sign paperwork to sign up for hospice, including a nurse or a doctor, Patient 5 stated ";no, no one else has come to my house. I havent talked to anyone else or signed any papers." During a telephone interview in the patient native language (Spanish) on 10/13/2023, at 10:43 am, with Patient 5, Patient 5 stated he did not accept to be in hospice. Patient 5 stated he did not know he was enrolled in hospice until yesterday 10/12/2023. He stated he does not remember the date when he inquired about a free cell phone service and spoke to someone (does not remember the name) and that person provided him with LVN 1 telephone #. Patient 5 stated he then called LVN 1 and LVN 1 told him he would receive free supplies as wipes, walker, recliner, cream, body wash, walking cane, and other supplies that he has to return back and did not explain the Hospice services. Patient 5 stated he remembers signing papers but does not remember the date when a man (unidentified) went to his house and had him sign the forms in English. He stated he does not know what he signed as the forms were in English and he only understands a little bit of English and prefers Spanish. He stated that no nurse has seen him nor assessing him until yesterday 10/12/2023, the first time a nurse went to his house to visit. Patient 5 stated he was confused because he does not have a terminal illness and wants to live many years (200 years) and that he only has diabetes and does not think diabetes is terminal. Patient 5 stated he has not seen nor heard from a Hospice doctor. b. A review of Patient 8s Patient Information Sheet indicated a Start of Care (SOC) of 8/28/2023 with a primary diagnosis of hypertensive heart disease with heart failure (high blood pressure with a chronic condition in which the heart doesn't pump blood as well as it should). A review of Patient 8s Certification of Terminal Illness (CTI), Certification #1: Certification Statement for Next 90-day period from 8/28/2023 to 11/25/2023 indicated Patient 8s primary diagnosis was hypertensive heart disease with heart failure. During a review of Patient 8s electronic medical record, the initial assessment, the comprehensive assessment, IDG/POC, LCD, nursing notes were left blank. During a telephone interview on 10/13/2023 at 2:40 p.m. in the patient native language (Spanish) with Patient 8, the husband of Patient 7. Patient 8 stated he does not remember when him and his wife were enrolled in a ";program," that offered them free supplies. Patient 8 stated his friend (Friend 1 ) referred him and his wife to LVN 1 who was friends with LVN 1 and the one who enrolled them to receive supplies. Patient 8 stated he and his wife received the following about a month ago for the first time and again about a week ago: Walker Diapers Gloves Shampoo COVID tests Wipes Patient 8 stated he feels bad because he does not need all the supplies and was thinking of giving the supplies to his church. Patient 8 stated he does not have a terminal illness and does not know what hospice is. Patient 8 stated no one has ever visited him or his wife. Patient 8 stated no nursing assessments were ever done and does not recall signing any HA forms. Patient 8 stated his wife (Patient 7) had pain as 9/10 and 10/10 (10/10, a numeric pain scale with zero as no pain and 10 over 10 as the worst pain) to her right arm and it was chronic and was only taking Tylenol (medication to relieve pain) and was not effective. Patient 8 stated he feels bad not knowing about the HA program, stated he does not have a HA binder at home for him or for his wife. During a phone interview on 10/13/2023 at 3:00 p.m., with Director of Patient Care Services (DPCS), when asked about Patient 5, Patient 6, and Patient 7, DPCS stated the initial assessment should have been done within 24-48 hours of admission. When asked why is it important to have a complete initial assessment, DPCS stated because the plan of care can not be generated with out a complete initial assessment. When asked if there is no initial assessment and can there be harm to the patient, DPCS stated yes because the care is not being provided to the patient. When asked how is care being provided for Patient 5, Patient 6, and Patient 7, DPCS stated the nurse who goes to see them for home visits should do their own assessments and reporting any unusual occurrences to the DCPS or MD. When asked if DPCS participated in any IDG meetings for Patient 5, Patient 6, Patient 7 and Patient 8, DPCS stated she has only received report for Patient 5 from LVN 2 regarding pain. When asked if she received any reports for Patient 5, Patient 6, Patient 7 and Patient 8, DPCS stated she did receive a report for Patient5 from LVN 2 regarding pain. During a concurrent interview and record review on 10/13/2023 at 3:30 p.m. with the ADM, when asked to provide Patient 8s hospice election consents, ADM stated, its not in his electronic medical record, and did not provide any consents for Patient 8. A review of the Patient 8's Initial comprehensive assessment, IDG notes, LCD, and nurse visit notes indicated the were left blank.

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 clinical records were completed and authenticated (genuine or real) by the author/HA staff (in general), for one of five sampled patients (Patient 5). This deficient practice resulted in clinical information entered in the patients records without validation of the accuracy of information and had the potential to affect the care and services for Patients 5. --- A review of Patient 5s Personal Information indicated a start of care (SOC) date of 9/14/2022, with diagnosis of hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) without heart failure (high blood pressure). A review of Patient 5s "Physician's Certification for Hospice Benefit", (CTI), for the first 90 day period from 9/19/2023 to 12/17/2023, indicated, a terminal diagnosis (an illness or condition which cannot be cured and is likely to lead to someone's death) of hypertensive heart disease without heart failure. The CTI has no Medical Director (MD) narrative notes (a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician). A review of Patient 5's consent for hospice election section were blank. During a concurrent interview and record review on 10/11/2023 at 2:15 p.m. with the Administrator (ADM), Patient 5's initial and comprehensive assessment, hospice consents, Local Coverage Determination (LCD), Plan of Care or Interdisciplinary Group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) were reviewed. ADM stated, ";we dont have Patient 5s initial and comprehensive assessment, hospice consents, LCD, Plan of Care or IDG notes in the Patient 5's file. All we have in the electronic medical record is the CTI, the factsheet and the medication list. The nurses did not submit any of these documents yet, Usually we give them like 3 weeks to submit since they have so many patients." When asked how the plan of care is developed if the initial comprehensive assessment is not in the system for the nurses to know what needs to be done during the home visits without all the documents in the file, ADM stated, ";the nurses just communicate with each other and do the home visits." The ADM stated, ";no we dont have the consent for Patient 5 in the office, the nurse that did the initial assessment has it." The ADM stated Registered Nurse 1 (RN 1) did the initial assessment and the Licensed Vocational Nurse 1 (LVN 1) was assigned for Patient 5. During a telephone interview on 10/11/2023 at 2:45 p.m., with Patient 5 in his native language (Spanish), Patient 5 stated, ";I am not familiar with any hospice agency, I never signed up for hospice. I recently went to those places where there are people that sign you up to get a free phone. I spoke to a lady and she gave me a phone number to call for other government benefits, and I called. I got some supplies but I never signed up for hospice. I never got any documents, I never signed any papers. Nobody has ever visited me, no doctor, no nurse from a hospice. I'm very healthy I don't have any issues to be on hospice, I only have diabetes (high blood sugar level). I know what hospice is and it's for patients that are going to die I'm not going to die." Patient stated, ";no like I said I'm not on hospice my primary care physician wouldn't refer me to be on hospice because Im not dying. I don't know how this agency got my information." During a joint home visit with Licensed Vocational Nurse 1 (LVN 1) on 10/12/2023 at 10:15 a.m., at Patient 5's residence and an interview, Patient 5 stated he did not know LVN 1, ";no, when I went to the those people that give free phones, there was someone there, I asked her if she knows of any other government agencies, and she gave me a number and said call this number and they will take care of you. I called the number and LVN 1 (pointing to LVN 1) answered the phone and came and visited me once." During an interview on 10/12/2023 at 10:15 a.m., with the LVN 1, LVN 1 stated, ";this patient is not my regular patient, the agency told me they needed an emergency visit for Patient 5, and I came, this is the second time I am coming here." LVN 1 stated she could not remember the last time she conducted a home visit to Patient 5. When asked if LVN 1 wrote a note for the visit, LVN 1 stated, ";no I didnt." LVN 1 asked Patient 5 if anyone else from the agency has come to visit Patient 5, nurses or a doctor, Patient 5 stated, ";no." LVN 1 asked patient 5 if Patient 5 signed any documents to sign on to hospice, the patient stated, ";no". LVN 1 asked Patient 5 if Patient 5 received any supplies, Patient 5 stated, ";I received a walker, a toilet extension, wipes, a body wash, and vitamins, thats it." During an interview on 10/12/2023 at 10:30 a.m. with the Patient 5, Patient 5 stated ";I see my primary care physician every three months. He never referred me to hospice. I dont have any issued other than diabetes. I know what hospice is. One of my friends had cancer a few years ago and he had hospice. It was a nice service, the nurses would come check on him and they would send a priest to the house. I dont have a condition like that. I only have diabetes" Patient 5 stated there was no staff came to visit him from the agency other than LVN 1, Patient 5 stated ";no, no one else has come to my house. I havent talked to anyone else or signed any papers." During a telephone interview on 10/13/2023, at 10:43 am, with Patient 5, Patient 5 stated he did not accept to be in hospice. Patient 5 stated he did not know he was enrolled in hospice until yesterday 10/12/2023. He does not remember the date when he inquired about a free cell phone service and spoke to someone (does not remember the name) and that person provided him with LVN 1 telephone #. Patient 5 stated he then called LVN 1 and LVN 1 told him he would receive free supplies as wipes, walker, recliner, cream, body wash, walking cane, and other supplies that he has to return back and did not explain the Hospice services. Patient 5 stated he remembers signing papers but does not remember the date when a man (unidentified) went to his house and had him sign the forms in English. He stated that no nurse has seen him nor assessing him until yesterday 10/12/2023, the first time a nurse went to his house to visit. Patient 5 stated he has not seen nor heard from a physician from the agency. During a concurrent interview and record review on 10/13/2023 at 3:00 p.m. with ADM, the electronic patient record audit log was reviewed. ADM stated, ";For example, on page 1, the modified date, which is 10/13.2023 at 1:48 p.m., shows that I printed the comprehensive nursing assessment for Patient 5." When asked about the modification made on 10/12/23 at 7:39 a.m., by RN 1 of the CTI physician narrative for Patient 5, ADM stated, ";There 2 parts for the narrative. The 1st part was done by the MD but obtained by the RN, so the RN was the one getting the information. The 2nd part has an RN assessment box and a physician summary box. That part is done by the both of them. RN 1 was doing the RN part and the physician part will be done by the MD." A review of the electronic audit log for Patient 5, indicated on 10/12/23 at 7:39 a.m., RN 1, modified the Physician Narrative: Certifying physician summary. During an attempted phone interview on 10/13/2023 at 3:28 p.m. with MD on cell, no answer, left message to call back. At 3:31 p.m. automated text message received from the MD cell phone number ";Sorry. I cant talk now". During an attempted phone interview on 10/13/2023 at 3:32 p.m. with MD office number. No answer. A left message to call back. During an attempted phone interview of 10/13/2023 at 3:36 p.m. with RN 1 phone number, no answer. A review of HAs policy and procedure titled ";Certification of Terminal Illness" revised November 2021, the policy indicated ";Patients who elect the hospice Medicare or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course, by the attending physician and the hospice Medical Director.... 1. At the time of admission to hospice, the hospice Medical Director or the patient's attending physician will complete a certification narrative that reflects the patient's individual circumstances based on: his/her review of the patient's medical record or, if applicable, examination of the patient. (The hospice Medical Director and the patient's attending physician will sign the certification of terminal illness and authorization for hospice services forms.) The certification may be completed no more than fifteen (15) calendar days prior to the effective date of the hospice election. 2. If written certification cannot be obtained within two (2) calendar days following the start of care, verbal certification must be obtained and documented in the clinical record within two (2) days following initiation of care and written certification must be obtained before the hospice submits a claim for payment. 3. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. Initially, the clinical information may be provided verbally, and must be documented in the clinical record and included as part of the hospice's eligibility assessment."

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 background checks (a process a person or company uses to check a person's criminal record, education, employment history, and other past activities) were performed on all employees and filed with the employee records. This deficient practice had the potential for unqualified personnel and/or had past record providing care and services to the patients, that could cause harm and safety to the patients. --- On 10/12/23, a review of the HA employee files was conducted. The employee record for Licensed Vocational Nurse 1 (LVN 1) was not found at the HAs office, making it unavailable for review. During interview on 10/13/23 at 1:30 p.m. with the Administrator (ADM), the ADM stated, ";We dont have LVN 1s file. She might have it. Probably her file was missing some stuff, so we gave it to her to complete it." The ADM stated, ";Were trying to contact her to see if she has it, or at least if she can send us her license or drivers license." During the same interview, the ADM stated it was important to do background check on all employees because it is related to patient safety.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation regarding Patient Rights were met as follows: --- 1. The HA failed to provide two of four sampled patients (Patient 1 and Patient 2) information regarding their rights as a hospice patient in a language and manner that would be understood and preferred by the patient. (Refer to L502). The cumulative effect of this systemic practice resulted in patients not knowing their hospice services with their limitations and their rights as hospice patients.

Based on observation, interview, and record review, the hospice agency (HA) failed to ensure the Condition of Participation regarding Patient Rights were met as follow: 1. The Notice of Information for two of four sampled patients (Patients 1 and 2) was written, explained, and provided in a language and manner that patients could understand. This deficient practice resulted in the patients not understanding what hospice service is about, its purpose, and had the potential to affect the patients quality of life and care. --- a. A review of Patient 1s Face sheet indicated a start of care (SOC) date of 10/01/2022, with a primary diagnosis of atherosclerosis heart disease of native coronary artery (a buildup of plaque consists of fats, cholesterol, and other substances inside the artery walls that can cause arteries to become narrow and can block the blood flow). A review of Patient 1s ";Physicians Certification for Hospice Benefit" (CTI, a written certification of terminal illness for a six month or less life expectancy), for the first 90 day period from 10/01/2022 to 12/29/2022, indicated a terminal diagnosis of atherosclerosis heart disease of native coronary artery. A review of Patient 1s Informed Consent and Treatment Authorization and Election of Hospice Medicare Benefit and Patient Authorization forms (intended to ensure that the beneficiary understands hospice benefits) dated 10/01/2022, indicated the text in both forms was written in English and was signed by Patient 1. Patient 1s face sheet indicated Patient 1's primary language was English. A review of Patient 1s Comprehensive Nursing Assessment dated 10/01/2022, in the narrative note section documented by the Director of Patient Care Services (DPCS), indicated ";Patient is awake with episodes of confusion, oriented x 3, able to make his needs known and speaks mostly Spanish, but is able to understand English." There was no documentation that the DPCS used a translator for Patient 1. During a telephone interview with Patient 1 and Family Member (FM1) on 7/12/2023 at 9:45 a.m., Patient 1 spoke fluent English and stated he speaks very little Spanish which is also confirmed by FM1. Patient 1 stated that he is not aware that he is on hospice program and stated he does not know about hospice. Patient 1 stated he did not sign any documents pertaining to hospice program and did not consent to be admitted under it. Patient 1 stated that if he speaks Spanish, he would definitely request for an interpreter to explain him hospice program and would request documents needed to be signed written in the language that he could understand. Patient 1 stated he does not remember nurses visited him from the hospice agency. Patient 1 stated that he was very surprised when he learned that he was under the hospice care when FM1 reviewed his insurance statements. During an interview with the DPCS on 7/13/2023 at 11:00 a.m., DPCS stated that she conducted the initial visit and comprehensive nursing assessment on 10/01/2022. The DPCS stated that Patient 1 speaks only Spanish, but was able to understand English. The DPCS stated that she should have documented if she used a translator for Patient 1. The DPCS stated that she did not offer a Spanish interpreter for Patient 1. b. A review of Patient 2s Face sheet, indicated an SOC date of 03/06/2023, with a primary diagnosis of hypertensive heart disease without heart failure (a series of changes in the chambers of the heart as a result of chronic blood pressure elevation). A review of Patient 2s ";Physicians Certification for Hospice Benefit" (CTI), for the first 90 day period from 03/06/2023 to 06/03/2023, indicated a terminal diagnosis of hypertensive heart disease without heart failure. A review of Patient 2s Informed Consent and Treatment Authorization and Election of Hospice Medicare Benefit and Patient Authorization forms dated 03/06/2023, indicated the text in both form was written in English language and was signed by FM 2. Patient 2s face sheet indicated Patient 2's primary language was English. A review of Patient 2s Comprehensive Nursing Assessment dated on 03/06/2023, indicated there was no documentation that translation or interpretation was offered to Patient 2 and FM2 to explain hospice benefits/programs. During a home visit with the Licensed Vocational Nurse (LVN 1) on 07/12/2023 at 11:00 a.m., FM2 stated that Patient 2 only speaks Armenian. LVN 1 spoke fluent in Armenian and translated for FM2 during the home visit. Per LVN 1, FM2 stated that she speaks Armenian and only speaks little English. FM2 stated that the hospice agency did not offer a translator during the explanation of the hospice benefits for her mother, as the nurse speaks her language. FM2 stated that it would be better if the documents are in the language that they could understand so that she does not need to ask a translation for it. FM2 stated that the forms she signed for Patient 2 are all in English language, and both Patient 2's and FM2's primary language was not English. During an interview with the DPCS on 07/13/2023 at 11:00 a.m., she stated that they should provide documents that are written in Patient 2's and FM2s primary language, so they can better understand the process. The DPCS stated that although the visiting nurses speak Armenian and were able to translate to Patient 2 and FM2, it should have been documented that translation was offered and provided by them. A review of the hospice agencys policy and procedure titled ";Patient Bill of Right/Responsibilities" revised on November 2021, indicated the purpose of the policy is to encourage awareness of patient rights and responsibilities, to provide guidelines to assist patients making decisions regarding care, and to support active participation in care planning. The policy indicated that in the event a communication barrier exists, if possible, special devices or interpreters will be made available, written information will be provided to patients in the predominant languages of the population served. A review of the hospice agencys policy and procedure titled ";Facilitating Communication" revised November 2021, indicated the purpose of the policy is to assure patients, visitors, and personnel with speech, vision, or hearing impairment, as well as those who have a limited command of the English language, have access to appropriate interpretive assistance and other aids at no cost to patient being served. The policy indicated that organization personnel will consistently and clearly communicate with patients in a language or form they can reasonably understand. The policy indicated the organization will facilitate communication by using interpreters or other communication aids. The initial assessment will determine the patients communication ability, and if there is any question regarding the patients ability to communicate properly, the assessment should stop and an interpreter should be secured. The policy indicated if the patient refuses offered communication assistance, the clinician will document the refusal in the patients clinical record. All patient related forms such as Consent for Services will be available in English and other languages as appropriate, if there is a need to translate the form to another language, an interpreter will be secured, the organization will maintain a list of organization personnel who speak languages other than English to assign an interpreter to non-English speaking patients. If an interpreter in the required language is not available, a telephone interpreting service may be used. All language assisted care should be documented in the patients clinical records.

Based on interview, and record review, the Hospice Agency failed to meet the Condition of Participation for the Comprehensive Assessment of Patients as follows: --- The hospice agency failed to conduct accurate comprehensive assessment of the skin integrity (skin is damaged, vulnerable to infection, injury or unable to heal normally) and failed to reflect in the clinical record the current skin condition for one of four sampled patients (Patients 1). Refer to L524. 1. For Patient 1, the hemodialysis port access (an access to provide hemodialysis, using the access, blood is removed from the body, cleaned by the dialysis machine (called the dialyzer), and then returned to the body) located at right upper chest area was not assessed. (Refer to L524). The cumulative effect of this practice resulted in the hospice Agency's inability to ensure the provision of quality health.

Based on interview and record review, the hospice Agency's skilled nurse failed to assess one of four patients hemodialysis access site (an access to provide hemodialysis, using the access, blood is removed from the body, cleaned by the dialysis machine (called the dialyzer), and then returned to the body) (Patient 1). This deficient practice resulted in the staff's failure to identify patient's care need and had a potential to result in the hemodialysis access not being managed and in failure to identify malfunctions and complications of the site in a timely manner and had the potential to result in harm to Patient 1. --- A review of Patient 1s Face sheet, indicated a start of care (SOC) date of 10/01/2022, with a primary diagnosis of atherosclerosis heart disease of native coronary artery (is the buildup of fats, cholesterol and other substances in and on the artery walls, the buildup is called plaque and it can cause arteries to narrow, blocking blood flow, it can also burst, leading to a blood clot). A review of Patient 1s ";Physicians Certification for Hospice Benefit", (CTI), for the first 90 day period from 10/01/2022 to 12/29/2022, indicated a terminal diagnosis of atherosclerosis heart disease of native coronary artery. A review of Patient 1s Comprehensive Nursing Assessment dated 10/01/2022, indicated no documentation of an assessment of Patient 1's hemodialysis access located at the right upper chest area. During a telephone interview with Patient 1 on 7/12/2023 at 9:45 a.m., Patient 1 stated that he has an hemodialysis access located at his right upper chest area. Patient 1 stated that during his stay at the assisted living facility in Los Angeles, he went to a dialysis outpatient clinic for his treatment three times a week. During an interview with the Director of Patient Services (DPCS) on 7/13/2023 at 11:30 a.m., she stated that she conducted the initial visit and comprehensive nursing assessment on 10/01/2022. DPCS stated that she noticed that Patient 1 had an hemodialysis access located at his right upper chest area, she stated that she did not include it in her assessment as the hospice agency does not manage his hemodialysis access and instead, he goes to a dialysis clinic for his treatment. DPCS stated that she should have included and acknowledge that Patient 1 had a dialysis access in her comprehensive assessment documentation. A review of the hospice agencys policy and procedure titled ";Comprehensive Assessment" revised November 2021, indicated that a physical assessment, includes blood pressure, temperature, pulse, respiration, skin, and other relevant data related to pertinent physical findings and the patients terminal illness.

Based on record review and interview, the agency failed to maintain a comprehensive and current care plan for two of 4 sampled patients (Patient 3, and Patient 4). This deficient practice had the potential to result in poor quality care and placed patients at risk for not receiving their physician ordered care. --- c. On 7-12-23, a review of PT 3s clinical record indicated PT3 was admitted to the hospice agency on 4-19-23 with a primary diagnosis of Hypertensive Heart Disease with heart failure. (unmanaged high blood pressure for an extended period of time progressing to heart failure) A review of the agencys document entitled Plan of Care dated 5-5-23 indicated Skilled Nurse visits of 1 time per week and CHHA visits of 1 time per week On 7-12-23 a review of the agencys document entitled ";plan of care" dated 5-5-23 indicated the following sections were not completed or updated by the agency. Section 7 diet, section 9 treatment, section 11 DME, section 12 supplies, and section 13 Lab. On 7-13-23 23 at 10:35am, an interview was conducted with the DPCS in the agency conference room. DPCS stated care plans for each patient should be reviewed monthly for accuracy and admits she hasnt had time to do this. d. On 7-12-23, a review of PT4s clinical record indicated PT4 was admitted to the hospice agency on 7-5-22 with a primary diagnosis of atherosclerotic heart disease (narrowing of the arteries supplying blood to the heart a review of the agencys document entitled ";Plan of Care summary" dated 7-11-23 indicated SN visits 1x/week and MSW visits 1x/month. A review of the agencys document entitled ";plan of care" dated 7-11-23 indicated the following sections were not completed or updated by the agency. Section 4 mental status, section 5 disaster triage, section 7 diet, section 9 treatment, section 11 DME, and section 12 supplies. On 7-13-23 23 at 10:35am, an interview was conducted with the DPCS in the agency conference room. DPCS stated care plans for each patient should be reviewed monthly for accuracy and admits she hasnt had time to do this. On 7-14-23 a review of the agencys policy entitled "; interdisciplinary group care plan" dated November 2021 indicated written evidence of care coordination will be found in the care plan. The interdisciplinary group will conduct assessments, develop and update the care plan, and review the effectiveness of care a minimum of every 15 calender days.

Based on observation, interview, and record review the agency failed to report abnormal vital signs to the MD for one of four sampled patients (Patient 3). This failure had the potential to place Patient 3 at an increased risk for adverse events. --- On 7/12/23, a review of Patient 3s clinical record indicated Patient 3 was admitted to the hospice agency on 4/19/23, with a primary diagnosis of hypertensive heart disease with heart failure. (unmanaged high blood pressure for an extended period of time progressing to heart failure) A review of Patient 3's Plan of Care dated 5/5/23 indicated the Skilled Nurse was to visit one time per week and the CHHA was to visit one time per week. On 7/12/23 at 10:30am an observation was made during Patient 3s home visit. LVN1 was observed taking Patient 3s blood pressure which was 145/111 (Normal range 120/80). LVN1 did not attempt to retake Patient 3's blood pressure and did not indicate this reading was going to be reported to the MD as ordered. On 7/12/23 during a record review of the physicians order dated 4/19/23, the order indicated the SN was to assess Patient 3's vital signs during every visit (temperature, blood pressure, heart rate, respiratory rate, oxygen saturation , and pain) and notify the physician if Patient 3's systolic blood pressure (SBP) was greater than 160 mmHg and less than 90 mmHg and Diastolic blood pressure (DBP) greater than 90 mmHg and less than 50 mmHg for :heart rate greater than 110 beats/min and less than 50 beats/min: respiratory rate greater than 26 or less than 10: temperature greater than 101F and oxygen saturation less than 90%: pain greater than 5/10 not relieved with rest and current prescription. The Physician orders further indicated to assess MAC (Mid arm circumference) monthly On 7/13/23 at 10:35am, an interview was conducted with the DPCS in the agency conference room. DPCS was able to confirm physician order for Patient 3 which was to notify MD if diastolic blood pressure was greater than 90 mmHg. Patient 3s diastolic blood pressure (DBP) was 111mmHg and no documentation could be provided that this was reported as ordered to MD. On 7/14/23. a review of the agencys policy entitled ";Monitoring patients response /reporting to physician" dated November 2021 indicated clinicians will establish and maintain ongoing communication with the patients physician and the hospice medical director to ensure safe and appropriate care for the patient.

Based on observation and interview, the agency failed to provide adequate infection control practices for one of four sampled patients (Patient 3). This deficient practice had the potential to place Patient 3 at an increased risk for the transmission of potentially harmful pathogens. --- On 7/12/23, a review of Patient 3s clinical record indicated Patient 3 was admitted to the hospice agency on 4/19/23 with a primary diagnosis of hypertensive heart disease with heart failure. (unmanaged high blood pressure for an extended period of time progressing to heart failure) A review of the Patient 3's Plan of Care dated 5/5/23 indicated the Skilled Nurse was to visit Patient 3 one time per week and CHHA visits one time per week On 7/12/23 at 10:30 a.m. an observation was made during a home visit. LVN1 was observed sanitizing her hands with an alcohol based sanitizer prior to entering the home. LVN1 proceeded with the home visit by initiating vital signs for Patient 3. No further hand washing or hand sanitizing was observed before initiating vitals. LVN1 did not sanitize the equipment used to monitor Patient 3's vitals. No sanitizing of equipment after vitals was done. On 7/13/23 at 10:35am an interview was conducted with DPCS in the agency conference room. DPCS stated LVN1 should have performed hand sanitizing immediately prior to taking the vitals for Patient 3. In addition, DPCS stated that equipment used for taking vital signs should have been sanitized before and after use. A review of the agencys policy entitled ";Infection Control Precautions" with a date of November 2021, indicated the policy is to provide guidelines in infection control precautions. Based on the assessment and patient needs, will receive information and instruction on standard precautions, including such information as hand washing, transmission of infections, and cleaning and decontamination schedules, if appropriate.

Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure the Condition of Participation for Core Services was met as evidenced by: --- The HA failed to ensure four of four sampled patient's (Patient 1, Patient 2, Patient 3 and Patient 4) was provided with the opportunity to receive spiritual counseling by not having a pastor on staff. (refer to L598). This deficient practice resulted in a the failure to provide spiritual care to meet the spiritual needs of the patient and family, which had the potential to affect their quality of life.

Based on observation, interview, and record review the Hospice Agency (HA) failed to provide spiritual counseling for four of four sampled patent's (Patient 1, Patient 2, Patient 3, and Patient 4). This failure resulted in the patients lack of having their spiritual needs met, which had the potential to affect their quality of life. --- c. On 7-12-23, a review of PT 3s clinical record indicated PT3 was admitted to the hospice agency on 4-19-23 with a primary diagnosis of Hypertensive Heart Disease with heart failure. (unmanaged high blood pressure for an extended period of time progressing to heart failure) A review of the agencys document entitled Plan of Care dated 5-5-23 indicated Skilled Nurse visits of 1 time per week and CHHA visits of 1 time per week On 7-12-23 record review of the agencys document entitled ";POC/IGD review" dated 4-21-23 and 5-5-23 indicated there was no chaplain signature. On 7-13-23 at 10:35am, an interview was conducted with the DPCS in the agency conference room. DPCS acknowledged that chaplain signature are missing for IDG review. DPCS stated agency currently has no chaplain and is actively trying to fill the position. d. On 7-12-23, a review of PT4s clinical record indicated PT4 was admitted to the hospice agency on 7-5-22 with a primary diagnosis of atherosclerotic heart disease (narrowing of the arteries supplying blood to the heart a review of the agencys document entitled ";Plan of Care summary" dated 7-11-23 indicated SN visits 1x/week and MSW visits 1x/month. On 7-12-23 record review of the agencys document entitled ";POC/IGD review" dated 6-20-23 and 7-4-23 indicated there was no chaplain signature. On 7-13-23 at 10:35am, an interview was conducted with the DPCS in the agency conference room. DPCS acknowledged that chaplain signature are missing for IDG review. DPCS stated agency currently has no chaplain and is actively trying to fill the position. a. A review of Patient 1s Face sheet, indicated a start of care (SOC) date of 10/01/2022, with a primary diagnosis of atherosclerosis heart disease of native coronary artery (is the buildup of fats, cholesterol and other substances in and on the artery walls, the buildup is called plaque and it can cause arteries to narrow, blocking blood flow, it can also burst, leading to a blood clot). A review of Patient 1s ";Physicians Certification for Hospice Benefit", (CTI), for the first 90 day period from 10/01/2022 to 12/29/2022, indicated a terminal diagnosis of atherosclerosis heart disease of native coronary artery. A review of Patient 1s updated Plan of Care Summary dated 12/30/2022, indicated Skilled Nurse visits of 1 time per week and 3 additional PRN (as needed) visits. A review of Patient 1s Plan of Care/Interdisciplinary Group (POC/IDG) dated 10/01/2022, 10/14/2022, 10/21/2022, 11/04/2022, 11/18/2022, 12/02/2022 and 12/16/2022 indicated there was no chaplain signature. b. A review of Patient 2s Face sheet, indicated a start of care (SOC) date of 03/06/2023, with a primary diagnosis of hypertensive heart disease without heart failure (a series of changes in the chambers of the heart as a result of chronic blood pressure elevation, hypertension increases the workload on the heart inducing structural and functional changes in the heart muscles). A review of Patient 2s ";Physicians Certification for Hospice Benefit", (CTI), for the first 90 day period from 03/06/2023 to 06/03/2023, indicated a terminal diagnosis of hypertensive heart disease without heart failure. A review of Patient 2s Plan of Care/Interdisciplinary Group (POC/IDG) dated 06/16/2023 and 06/30/2023 indicated there was no chaplain signature. During an interview with the Director of Patient Care Services (DPCS) on 7/13/2023 at 10:35am, she acknowledged that chaplain signatures are missing for POC/IDG review. DPCS stated that agency is currently has no chaplain and is actively trying to fill the position. DPCS was not able to provide documented evidence that agency is actively hiring a chaplain. DPCS stated that Social Worker (SW) is filling in the duty of the chaplain. During an interview with the Social Worker (SW) on 7/13/2023 at 11:00 a.m., she confirmed that she is filling in the duty of a chaplain, she stated that she is qualified to do it. SW stated that she attends IDG meeting, however, she stated that she is not aware that she needs to conduct a spiritual assessment as well to IDG notes. A review of the hospice agencys policy and procedure titled ";Spiritual Care Counseling Services", revised November 2021, indicated that the hospice chaplain (or designated spiritual care counselor) will provide direct support and coordinate services utilizing local clergy and other individuals, as appropriate, a chaplain will be assigned to each patient based on the patients needs and acceptance of these services and the chaplain will be a member of the interdisciplinary group and will participate in the development, implementation and revision of the plan of care. A review of the hospice agencys policy and procedure titled ";Spiritual Assessment", revised November 2021", indicated that a spiritual assessment will be completed for each patient/family by the Hospice Chaplain and if the patient and/or family/caregiver refuse these services, the refusal will be documented, and the interdisciplinary group members will continue to assess for spiritual needs and offer appropriate services to the patient and/or family/caregiver.