Every finding on record at First Class Hospice, Inc.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation regarding Patients' Rights was met as follows: --- 1. Failed to ensure two of 14 sampled patients (Patient 3 and Patient 4) received information regarding their rights as certified hospice patient in a language that would be understood and preferred by the patient. This deficient practice resulted in the patients/families' lack of understanding of the hospice care and services provided which could impact their quality of care and well-being. (Refer to L502). 2. Failed to ensure two out of 14 sampled patients (Patient 3 and Patient 4) received information about hospice provision of care and services and the limitations of these services. This failure had resulted in the certification of these patients for hospice care lacking the knowledge and understanding to be eligible to receive the hospice benefits. (Refer to L519). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated Federal compliance for Patients' Rights to ensure their rights are not violated and receive the highest quality of hospice care.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure two of 14 sampled patients (Patient 3 and Patient 4) received information regarding their rights as certified hospice patient in a language that would be understood and preferred by the patient. This deficient practice resulted in the patients/families' lack of understanding of the hospice care and services provided which could impact their quality of care and well-being. --- A review of Patient 3s Personal Information document, indicated a Start of Care (SOC) date of 10/1/2024, with a primary diagnosis of Alzheimers Disease (a brain disorder that gradually destroys memory and thinking skills, eventually leading to the inability to perform simple tasks). The document indicated that Patient 3 spoke Spanish. A review of Patient 3s medical record titled, ";Certificate of Terminal Illness," dated 1/29/2025, for recertification of hospice services for the period of 1/29/2025 to 3/29/2025, indicated that Patient 3 was ";confused most of the time, has shortness of breath of exertion, patient in ambulatory using assistive device (Mobility aids, such as wheelchairs, scooters, walkers, canes, crutches), requiring maximum assistance with on ADL (activities of daily living- term used to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility.) A review of Patient 3s medical record titled, ";Informed Consent and Treatment Authorization," dated 10/1/2024, was written in English. A review of Patient 3s medical record titled, ";Physician Orders for Life Sustaining Treatment (POLST), signed 10/1/2024, by Patient 3s representative, was in English. The POLST indicated that Patient 3's status was "Do Not Attempt Resuscitation/DNR". During an interview on 3/11/2025 at 3:45 pm., with Patient 3s daughter as Representative (REP 3) stated Patient 3 was Spanish speaking only. REP 3 stated that Patient 3 cannot read or write and that she signs for him. REP 3 stated she did not understand that hospice was for terminally ill persons and that the consent forms given to her to sign were in English. REP 3 stated, Patient 3 wishes to have all measures done in case of an emergency and that the POLST was never given in Spanish for her to review. REP 3 stated that DNR status on the POLST form was not correct. During a concurrent interview and record review of Patient 3s medical file on 3/12/2025 at 10:30 am, DPSCD stated that the hospice consents and POLST should be provided in the language of the patient or the patients representative to make sure that they fully understand what they are signing and that the hospice agency did not offer Patient 3s representative the forms in their native language. A review of Patient 4s Personal Information document, indicated a Start of Care (SOC) date of 8/2/2024, with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where the heart's arteries are narrowed by plaque buildup, leading to chest pain of an unspecified type which is a symptom of coronary artery disease). The document indicated that Patient 4 spoke Spanish. A review of Patient 4s medical record titled, ";Certificate of Terminal Illness," dated 8/2/2024, for initial certification of hospice services for the period of 8/2/2024 to 10/30/2024, indicated that Patient 4 had end stage heart failure (condition that occurs when your heart can't pump enough blood for your body's needs) with a life expectancy of 6 months or less to live. A review of Patient 4s medical record titled, ";Informed Consent and Treatment Authorization," dated 8/2/2024, was written in English. During an interview on 3/12/2025 at 3 pm, Patient 4 stated that she spoke Spanish only. She stated that the consent forms for hospice were not offered to her in Spanish but were given to her in English. She stated that she did not know the services were for terminally ill patients and that she was not terminally ill. During a concurrent interview and record review on 3/13/2025, DPSCD stated that Patient 4 was given consent forms in English not Spanish. A review of the facilitys policy titled, ";Patient Bill of Rights/Responsibilities," dated April 2020, indicated that, ";explanation will be in a language and manner he/she (the patient) can reasonably be expected to understand."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure two out of 14 sampled patients (Patient 3 and Patient 4) received information about hospice provision of care and services and the limitations of these services. This failure had resulted in the certification of these patients for hospice care lacking the knowledge and understanding to be eligible to receive the hospice benefits. --- A review of Patient 3s Personal Information document, indicated a Start of Care (SOC) date of 10/1/2024, with a primary diagnosis of Alzheimers Disease (a brain disorder that gradually destroys memory and thinking skills, eventually leading to the inability to perform simple tasks). The document indicated that Patient 3 is Spanish Speaking. A review of Patient 3s medical record titled, ";Certificate of Terminal Illness," dated 1/29/2025, for recertification of hospice services for the period of 1/29/2025 to 3/29/2025, indicated that Patient 3 was ";confused most of the time, has shortness of breath of exertion, patient in ambulatory using assistive device (Mobility aids, such as wheelchairs, scooters, walkers, canes, crutches), requiring maximum assistance with on ADL (activities of daily living- term used to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility.) A review of Patient 3s medical record titled, ";Informed Consent and Treatment Authorization," dated 10/1/24, was written in English. During an interview on 3/11/2025 at 3:45 pm, Patient 3s Representative (REP 3) stated that she was Spanish speaking only. She states that Patient 3 cannot read or write and that she signs for him. She stated she does not understand that hospice was for terminally ill persons and that the consent forms were only in English. During a concurrent interview and record review of Patient 3s medical file on 3/12/2025 at 10:30 am, DPSCD stated that the hospice consents should be provided in the language of the patient or the patients representative to make sure that they fully understand what they are signing, and that the hospice agency did not offer Patient 3s representative the forms in their native language. A review of Patient 4s Personal Information document, indicated a Start of Care (SOC) date of 8/2/2024, with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where the heart's arteries are narrowed by plaque buildup, leading to chest pain of an unspecified type which is a symptom of coronary artery disease). The document indicated that Patient 3 was Spanish speaking. A review of Patient 4s medical record titled, ";Certificate of Terminal Illness," dated 8/2/2024, for initial certification of hospice services for the period of 8/2/2024 to 10/30/2024, indicated that Patient 4 had end stage heart failure (condition that occurs when your heart can't pump enough blood for your body's needs) with a life expectancy of 6 months or less to live. A review of Patient 4s medical record titled, ";Informed Consent and Treatment Authorization," dated 8/2/2024, was written in English. During an interview on 3/12/2025 at 3 pm, Patient 4 stated that she was Spanish speaking only. She stated that the consent forms for hospice were in Spanish but were given to her in English. She stated that she did not know the services were for terminally ill patients and that she was not terminally ill. During a concurrent interview and record review on 3/13/2025, DPSCD stated that Patient 4 was given consent forms in English not Spanish. A review of the facilitys policy titled, ";Patient Bill of Rights/Responsibilities," dated April 2020, indicated that, ";explanation will be in a language and manner he/she (the patient) can reasonably be expected to understand." A review of the facilitys policy titled, ";Hospice Election Statement," dated April 2020, indicated that the patient and family/caregiver, or his/her legal representative will be asked to sign the hospice election statement which acknowledges, ";a full understanding of hospice care." A review of the facilitys policy titled ";Admission Criteria and Process," dated April 2020, indicated that admission criteria for hospice care includes, ";the patient must desire hospice services, and be aware of the diagnosis and prognosis.";

Based on observation, interview and record review, the Hospice Agency  (HA-a healthcare organization that provides specialized to terminally ill [patients who have six months or less to live] patients) failed to ensure the Condition of participation (conditions that health care organizations must meet in order 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) regarding comprehensive assessments (an assessment used to evaluate a patient's overall health, including identifying the patients need for hospice care) were met as follows: 1.  Failed to ensure an accurate comprehensive assessment was conducted that addressed the hospice identified needs and well-being for three of 14 sampled patients (Patients 1, 2, and 9). This failure resulted for these patients being certified for hospice services, lacking comprehensive screening of the clinical information and comprehensive assessment of the patient’s identified needs for hospice care and eligibility. (Refer to L524). 2.  Failed to ensure that a review of the medication profile (comprehensive record of all the medications that a patient is currently taking) for all currently prescribed medications was done and was reflected accurately on the physician’s orders for one of 14 sampled patients (Patient 1) (Refer to L530). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated Federal compliance for Initial & Comprehensive Assessment of Patient to ensure patients certified for hospice services meet the eligibility requirement in order to receive the hospice benefits. --- .

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure an accurate comprehensive assessment was conducted that addressed the hospice identified needs and well-being for three of 14 sampled patients (Patients 1, 2, and 9).This failure resulted for these patients being certified for hospice services, lacking comprehensive screening of the clinical information and comprehensive assessment of the patient’s identified needs for hospice care and eligibility. --- a. A review of Patient 1s Patient Intake form (Face sheet- a document of a patients personal information such as diagnoses, date of birth, address, etc.) indicated a Start of Care (SOC) date of 2/23/2025. Patient 1 had a primary terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where the heart's arteries are narrowed by plaque buildup, leading to chest pain of an unspecified type which is a symptom of coronary artery disease). A review of Patient 1s Hospice Referral (a formal request for a patient to receive hospice care [a type of care focused on comfort and quality of life for individuals with a life -limiting illness] from a healthcare professional) was signed by the Medical Director Designee (MD2) dated 2/23/2025. The referral indicated for a hospice evaluation for diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. A review of Patient 1s History and Physical (a document that describes a persons medical history) from a visit to an emergency department (ER), dated 9/1/2022, indicated that Patient 1 had a past medical history of diabetes mellitus (disease where too much sugar is in the blood which can lead to serious health problems), hypertension (high blood pressure), and stroke (damage to the brain from interruption of its blood supply). Assessment of Patient 1s heart indicated that that had a regular rate and rhythm. An electrocardiogram (EKG-a non-invasive test that records the electrical activity of the heart that can be used to diagnose heart conditions such as irregular heartbeats, heart attacks, heart failure and assess the overall health of the heart) test was preformed and came back normal. No blood tests to test for cholesterol (fat levels in blood that can cause atherosclerotic heart disease and stroke) were completed during Patient 1s ER visit. A review of Patient 1s Initial Nursing Comprehensive Assessment, dated 2/23/2025, completed by Director of Patient Care Services Designee (DPCSD), indicated the following: 1. Under Cardiovascular Status indicated that Patient 1 has a diagnosis of congestive heart failure (CHF-when the heart cannot pump enough blood for the bodys needs). 2. Under Respiratory Status indicated Patient 1s breathing was labored and shallow. Oxygen saturation (amount of oxygen in the blood: normal 95%) 89%, patient was on 2 liters (L: unit of measurement) of oxygen per minute. The nursing assessment indicated Patient 1 has clear, but diminished breathe sounds on upper (lung) lobes bilaterally. Patient reported episodes of shortness of breath (SOB) with minimal exertion. Patient used deep breathing technique. The document indicated that oxygen treatment was initiated for the SOB on 2/23/2025. 3. The Nursing Narrative note stated that Patient 1 was dependent in all activities of daily living (ADLs) with moderate to maximum assistance. Unable to carry out any physical activity without discomfort. Skilled nurse (SN) administered oxygen to facilitate breathing and controlled SOB. During an observation and interview at Patient 1s home on 3/11/2025, at 10 am, Patient 1 was observed positioning himself with minimal assistance, and when at rest the respirations were noted to be even with no exertion. Patient 1 vital signs (measurements that indicate a persons basic physiological functions such as temperature, heart rate, respiratory rate, blood pressure and oxygen saturation) were within normal limits and his oxygen saturation was 96% on room air. Patient 1s family representative stated that Patient 1 does not use oxygen, needs assistance with walking, but can feed and administer his medications independently. During a concurrent interview and record review on 3/13/2025, at 3:40 pm, DPCSD confirmed that patient had no documented evidence Patient 1 had CHF. DPCSD also stated that since admission Patient 1s oxygen has been 90 % or above, so oxygen was never ordered for him. The note where she documented that patient was on 2L of oxygen was incorrect and never received oxygen as a treatment. b. A review of Patient 2s Face sheet indicated a SOC date of 3/1/2025. Patient 2 had a primary terminal diagnosis of atherosclerotic heart disease of native coronary artery with refractory angina pectoris. A review of Patient 2s Hospice Referral was signed by the Medical Director (MD1) and dated 3/1/2025. The referral diagnosis was atherosclerotic heart disease of native coronary artery with unstable angina pectoris. A review of Patient 2s Initial Nursing Comprehensive Assessment, dated 3/1/2025, completed by Director of Patient Care Services Designee (DPCSD), indicated the following: 1. Under Cardiovascular Status it states that Patient 2 experiences palpitations (sensation that the heart is racing, pounding, fluttering, or skipping a beat) and fatigues (tires) easily. That document also indicated Patient 2 had a diagnosis of CHF. 2. Under Gastrointestinal assessment it stated that Patent 2 suffered from constipation and was instructed to take Docusate Sodium (Colace-medication to treat constipation) 100 milligrams (mg-unit of measurement) 1 tablet once a day. 3. Under Vital Signs, Patient 2s blood pressure (BP) was documented as 89/78 (normal: 120/80). 4. The Nursing Narrative assessment indicated Patient 2 had a history of coronary artery disease with stents (a small, expandable metal tube that is inserted into a narrowed or blocked coronary artery [the arteries that supply blood to the heart]. Its purpose is to keep the artery open and improve blood flow to the heart), stroke with left sided deficits (weakness) and recent intercranial bleed...chest pain was reported at time of admission and slightly elevated blood pressure...patient reported that he is having uncontrolled elevated BP. Constipation controlled with Docusate 100mg once a day. A review of Patient 2s medication profile showed that there was no Colace ordered for Patient 2. During an interview on 3/1//2025, at 11:15am, Patient 2s family representative (REP 2) said they heard about the hospice agency through a brochure and called them because they were having issues getting a doctors appointment with the patients primary. When asked who the patients primary physician was, she stated she didnt recall the name, but when they would call, they were told all appointments are in three months. REP 2 stated it is so much easier with hospice, the nurse comes every week and takes care of Patient 2 and its very convenient. During an interview on 3/14/2025, at 11:03 am, DPCSD stated that Patient 2 was a self-referral, she did not have an H&P or any medical documents for the patient, and the Patient 2 does not have a primary care physician. DPCSD stated that Patient 2 was taking Colace, but the medication was not ordered at time of admission, she did not know why. DPCSD stated that she was told that Patient 2 had a history of cardiac stents (tubular support placed temporarily inside a blood vessel) by the family, but she does not know when the stents were placed, and she has no documented proof that stents were placed. DPCSD stated that her documentation about Patient 2 having a recent intercranial bleed was incorrect, he did not have bleeding. DPCSD also stated that Patient 2 did have an elevated BP and she gave him Lisinopril (BP medication) and the 89/78 was the BP reading after the medication was given. DPCSD stated that she did not document the elevated BP level, or that she gave a BP medication. DPCSD stated that she should have documented the care preformed for proof of what was going on with the patient and of what care she provided. c. A review of Patient 9s Face sheet indicated a SOC date of 3/1/2025. Patient 9 had a primary terminal diagnosis of combined systolic and diastolic congestive heart failure. A review of Patient 9s Hospice Referral was signed by the Medical Director (MD1) and dated 3/1/2025. A review of Patient 9s Initial Nursing Comprehensive Assessment, dated 3/1/2025, completed by Director of Patient Care Services Designee (DPCSD), indicated the following:1. Under Cardiovascular Status comments it states that Patient 9 was on 3 liters oxygen continuously. 2. Under Vital Signs, Patient 9s blood pressure (BP) was documented as 98/67 (Normal BP: 120/80). 3. The Nursing Narrative note indicated that Patient 9 was feeling unwell due to elevated BP. After promptly administering the prescribed medication the patients condition showed marked improvement and BP gradually stabilized to its normal level... At the beginning of the assessment the patient had difficulty in breathing and chest pain due to low oxygen level. I administered oxygen which alleviated these symptoms and stabilized the patients condition. During an interview on 3/13/2025, at 11:29 am, Patient 9s primary physician (PP1), stated that she was unaware that Patient 9 was signed up with hospice. PP1 stated that she last saw Patient 9 on 1/21/2025 and her next appoint is in April 2025. PP1 stated that Patient 9 was healthy, she only has chronic kidney disease. Patient 9s heart was good; she has a heart valve issue, but it is not to the point where she is in heart failure. PP1 stated that in her opinion Patient 9 was not eligible for hospice. During an interview on 3/14/2025, at 11:03 am, DPCSD stated that Patient 9 was a self-referral, she does not have a H&P and she never tried to contact the patients primary physician to confirm diagnoses. DPCSD stated that her documentation of Patient 9 being on 3 liters oxygen was incorrect. She was only on 2 liters as needed. DPCSD stated that she did not document what the patients elevated BP was, and she did not document what BP medication were given. During an interview on 3/15/2025, at 12:30pm, the DPCSD stated that it is important to have a H& P or medical documents for patients because it helps with proof of eligibility to hospice. DPCSD stated that patients are usually not knowledgeable about their health conditions, and do not have all the details. The H& P would have all that information such as diagnoses, supportive information about the diagnoses, lab results and surgical history. The DPCSD also stated that it is important to have accurate nursing assessments because it gives the heath status of the patient and what is going on with the patient. A review of the Agencys policy titled ";Comprehensive Assessment", dated 4/2020, indicated that 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... a. Patients past and present medical and psychosocial history including pertinent diagnosis and any co-morbid conditions. b. Name of the hospital and other agencies or persons involved in the past and present care of patient. c. Review of current and related past medications and whether the medication is unrelated to the terminal illness or related conditions (ensure that there is clinical documentation to support relatedness) d. Past medical and surgical care, including dates of onset/exacerbation. The assessment should determine probably prognosis of six (6) months or less and patient problems and needs related to the terminal illness.

Based on observation, interview, and record review, the Hospice Agency (HA, a healthcare agency that provides care for terminally ill patients with life expectancy of 6 months or less) failed to ensure that a review of the medication profile (comprehensive record of all the medications that a patient is currently taking) for all currently prescribed medications was done and was reflected accurately on the physician’s orders for one of 14 sampled patients (Patient 1). This failure had the potential to result in medication errors, and adverse drug reactions that could affect the health and safety of the patients. --- A review of Patient 1s Personal Information document, indicated a Start of Care (SOC) date of 2/23/2025, with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where the heart's arteries are narrowed by plaque buildup, leading to chest pain of an unspecified type which is a symptom of coronary artery disease). A review of Patient 1s medical record titled Plan of Care (POC) Summary with as of date of 2/23/2025, indicated an order for Skilled Nurse (SN) to visit once a week for 90 days, chaplain as needed one visit every recertification or as needed starting SOC, and Medical Social Worker as needed one visit every recertification or as needed starting on SOC. A review of Patient 1's medical record Medication Profile, dated 2/23/2025, indicated a physician's order for the medication: Ibuprofen (anti-inflammatory medication that is also used to treat pain) 800 milligrams (mg, unit of measurement) 1 tablet orally once daily, Louvaza (medicine used to lower very high triglyceride or fat levels in adults) 2 grams 1 tablet orally once daily. During an observation on a joint home visit on 3/11/2025 at 10 am., with Licensed Vocational Nurse 1 (LVN1), at Patient 1s home, the patient was observed awake, alert, oriented to self, time and location and spoke Armenian. Patient 1 was observed able to position himself with minimal assistance, sitting upright, and once at rest respirations were noted even and with no exertion. Patient 1s vital signs (essential measurements that indicate a person's basic physiological functions) were all within normal limits. Patient 1 was observed breathing with normal on room air without the use of oxygen. During an interview on 3/11/2025 at 10:15 am., with Patient 1s Family Member 1 (FM1), stated Patient 1 was oriented to self, time and location and was able to self-administer his medications daily. During a concurrent interview and record review on 3/11/2025 at 10:20 am., with LVN1 at Patient 1s home, Patient 1s medication profile, and medication bottles were reviewed. The dosage of Ibuprofen Patient 1 had at the home was 600 mg. LVN1 stated this was missed by her and she will have the pharmacy correct the dose since the medication profile indicated Ibuprofen dosage as 800 mg. During a concurrent interview and record review on 3/11/2025 at 10:25 am., with LVN1 at Patient 1s home, Patient 1s medication profile, and medication bottles were reviewed. The dosage of Louvaza on the medication profile indicated to take 1 tablet once a day orally, but the pharmacy dispensed medication bottle for Louvaza in Patient 1s home indicated to take 2 tablets by mouth once a day and the medication bottle did not indicate the strength of the medication. LVN 1 stated, since Patient 1 is a new patient she will follow up with the pharmacy to correct this. She stated this was missed. During an interview on 3/11/2025 at 12:10 pm., with Director of Patient Care Services Designee (DPCSD), DPCSD stated, ";The skilled nurse that does the home visits is responsible to check all the medications the patient has and update it in the HA system. If there are any discrepancies this needs to be addressed with the doctor. LVN 1 should have checked and updated Patient 1s medication to match our medication profile." During a review of HAs policy and procedures (P&P), titled ";Medication Profile," dated 4/2020, P&P indicated the following: 1. Patients receiving medications administered by the HA must have a current, accurate medication profile in the clinical record. 2. The medication profiles will be updated for each change to reflect the current medications and new and/or discontinued medications. 3. A drug regimen review must be performed by a registered nurse (RN) at the time of initial and comprehensive assessment, when updates to the comprehensive assessment are performed, when care is resumed after a patient has been placed on hold, and with the addition of a new medication. 4. The drug regimen review must identify the following: 1) effectiveness, 2) actual or potential side effects, 3) allergic reactions, 4) changes in the patients condition that contraindicates continued administration of the medication, 5) actual and potential drug interactions, and 6) duplicate drug therapy. 5. During subsequent home visits, the medication profile must be used as a care planning and teaching guide to ensure that the patient and family/caregiver, as well as other clinicians, understand the medication regimen. 6. Based on review of the medication profile as well as the written material, changes in the plan of care may be required. 7. Deviations from taking medications as ordered must be documented in the clinical notes, and the physician (or other authorized independent practitioner) will be notified.

Based on 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 (HA) failed to ensure the medical director or physician designee reviews the clinical information for each hospice patient to verify that it is anticipated that the patient's life expectancy is 6 months or less, if the illness runs its normal course for six of 14 sampled patients (Patients 1, 2, 6, 7, 8, and 9).  This deficient practice resulted in patients admitted and certified for hospice care without clinical evidence to support their terminal diagnoses. (Refer to L 667). Hospice Agency (HA) failed to ensure the medical director and/or physician designee verified the patient's clinical information to determine the patient's need for recertification to hospice to continue services for four of 14 sampled patients (Patients 3, 4, 5 and 10). This deficient practice resulted in patients remaining on hospice care without assessment and who did not need hospice care and management of terminal illness and not receiving appropriate care services that could affect their quality of life. (Refer to L668). 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 the highest quality of patient care are provided to the patients certified to receive hospice benefits. --- .

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the patient's eligibility for hospice services related to the palliation (relief of symptoms and suffering cause by life threatening diseases) and management of the terminal illness and related conditions were assessed for 9 of 14 sampled patients (Patients 1, 2, 3, 4, 5, 6, 7, 8, and 9). This deficient practice resulted in patients admitted and certified for hospice care without clinical evidence to support their terminal diagnoses. --- A review of Patient 3s medical record titled, ";Certificate of Terminal Illness, dated, 1/5/2024, for the initial hospice certification period of 1/5/2024 to 4/3/2024, indicated that Patient 3 had a diagnosis of Alzheimers and was terminally ill with six months or less (to live). The documented also stated that Patient 3 was ";alert and oriented times 1(only aware of self), has shortness of breath with minimal exertion, with wheelchair." The record also indicated that Patient 1 was, ";unable to carry on any physical activity without discomfort, needs maximum assist." During an observation on 3/11/2025 at 3:15 pm, Patient 3 was observed independently getting out of a sofa chair and walking 10 feet to sit in another chair he preferred to sit in. He was observed walking without an assistive device (walker, wheelchair, cane). Patient 3 was asked to remove his jacket so LVN 1 could take his blood pressure. Patient 3 understood and was then observed independently removing his jacket and then putting his jacket back on afterwards. During an interview on 3/11/2025 at 3:45 pm, Patient 3s representative (REP 3) stated that Patient 3 is able to dress, bathe, eat walk independently. REP 3 stated that Patient 3 gets some confusion, but that hes always been that way. During an interview on 3/11/2025 at 3:50 pm, Patient 3 was able answer questions regarding his weight, including how much we weighed, recent weight loss and gains. Patient 1 was observed conversing meaningfully with REP 3 in complete sentences and thoughts. During an interview on 3/14/2025 at 1:40 pm, Medical Director (MD1) stated that for a patient to be eligible for hospice care with a diagnosis of Alzheimers, that the patient should not be able to sit a chair that does not have arm supports, that the patient would fall over. MD1 stated that a patient with Alzheimers on hospice services would have advanced dementia and that would mean the patient would not be able to independently take care of own needs such as bathing and that they would forget everything and gave the example of not recognizing caregivers or family members. MD1 stated that the patient could communicate their needs but that maybe they would forget the words sometimes. MD1 did not know the LCD guidelines to determine eligibility for hospice for patients with Alzheimers Disease. During an interview on 3/13/2025 at 4:18 pm, DPCSD stated that there were medical records obtained prior to hospice admission to support the terminal diagnosis. The primary care physician was not contacted for information. A review of Patient 4s Personal Information document, indicated a Start of Care (SOC) date of 8/2/2024, with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where the heart's arteries are narrowed by plaque buildup, leading to chest pain of an unspecified type which is a symptom of coronary artery disease. A review of Patient 4s medical record titled, ";Certificate of Terminal Illness," dated 8/2/2024, for initial certification of hospice services for the period of 8/2/2024 to 10/30/2024, indicated that Patient 4 had end stage heart failure (condition that occurs when your heart can't pump enough blood for your body's needs) with a life expectancy of 6 months or less to live. The document also indicated that Patient 3 was diagnosed with ventricular arrhythmias (irregular heart rhythms that originate in the lower chambers of the heart, known as the ventricle) and was optimally treated with diuretics (medication that helps the body get rid of extra fluid) and vasodilators (medication that relaxes blood vessels allowing blood to flow easier). During an interview on 3/12/2025 at 3 pm, Patient 4 stated she stated that she did not know the services were for terminally ill patients and that she was not terminally ill. Patient 4 stated that she is unaware of any heart issues and does not suffer from shortness of breath. During a concurrent interview and record review of Patient 4s medical file on 3/13/2025 at 4:30 pm, DPCSD stated that the HA does not have any records from the primary care physician or previous care providers to support the diagnoses of ES heart failure for Patient 4. DPCSD also stated that Patient 4 was not currently of diuretics therapy. A review of Patient 5s Personal Information document, indicated a Start of Care (SOC) date of 8/6/2024, with a primary diagnosis of hypertensive heart failure (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 5s medical record titled, ";Certificate of Terminal Illness, dated 8/6/2024, for the first hospice certification period of 8/6/2024 to 11/3/2024, indicated that Patient 5 was terminally ill with a life expectancy of 6 months or less to live. The document also indicated that Patient 5 had hypertensive heart disease with heart failure, unresponsive to Lasix (diuretic) therapy, had edema (swelling caused by too much fluid trapped in the bodys tissues), has shortness of breath that results her needing assistance with all ADLs, and that she is in ";poor state of health." The documented indicated that Patient 5 was eating 45-50% of meals. A review of Patient 5s medical record titled, ";Discharge Summary," dated 7/9/2023 indicated that the patients left ventricle (left chamber of the heart) was within lower limits of normal function, with an ejection fraction (EF- measures your heart's ability to pump oxygen-rich blood out to your body) of 55-60%. The document also indicated that Patient 5s right ventricle (chamber in the right side of the heart) was normal in function and size. A review of Patient 5s Medication Profile indicated that Patient 5 was not on Lasix therapy, or any diuretic therapy. The document further indicated that Patient 5 was on Ozempic (a drug used for weight management) for weight loss. During an interview on 3/14/2025 at 10:50 am, DPCSD stated that Patient 5s medical record did not have any other contents to support the diagnosis of terminal heart failure. DPCSD stated no other records were requested to support the eligibility for hospice. A review of Patient 6s Personal Information document, indicated a Start of Care (SOC) date of 12/19/2024, with a primary diagnosis of hypertensive heart disease with heart failure (heart failure, caused by prolonged high blood pressure (hypertension), leading to structural and functional changes in the heart). A review of Patient 6s medical record titled, ";Certificate of Terminal Illness," dated 12/19/2024, for initial certification of hospice services for the period of 12/19/2024 to 3/18/2025, indicated that Patient 4 hypertensive heart failure with a life expectancy of 6 months or less to live. The document also indicated that Patient 6 was poorly responsive to dialectics, vasodilators and nitrates(medication used for treated heart pain). A review of Patient 6s medical record titled, ";Medication Profile", indicated that Patient 6 was Furosemide 20mg twice weekly (furosemide is a diuretic with dosing that can be up to 80mg per day). There was no indication that Patient 6 was taking nitrates. During a concurrent interview and record review of Patient 6s medical record on 3/14/2025 at 11 am, DPCSD stated that Furosemide 20 mg twice weekly is a lower dose of diuretic therapy. DPCSD stated the HA did not have any supportive medical history records or diagnostic tests to support the diagnoses of end stage heart failure. DPCSD stated that there was no contact attempted to obtain records to determine Patient 6s heart condition from either the primary care provider or previous medical providers. A review of Patient 7s Personal Information document, indicated a Start of Care (SOC) date of 2/16/2025, with a primary diagnosis of chronic combined systolic congestive(occurs when the left ventricle (the heart's main pumping chamber) weakens and can't contract normally, leading to reduced blood flow to the body) and diastolic congestive heart failure(occurs when the heart's left ventricle stiffens and can't relax properly, preventing it from filling with enough blood between beats, leading to reduced blood pumping and symptoms of heart failure). A review of Patient 7s medical record titled, ";Certificate of Terminal Illness," dated 2/16/2025, for initial certification of hospice services for the period of 2/16/2025 to 5/16/2025, indicated that Patient 7 was qualified for hospice services per LCD (local coverage determination- a guideline to help determine hospice eligibility) with a life expectancy of 6 months or less to live. The document also stated that Patient 7 was not responsive to diuretic therapy, had edema in both lower extremities, shortness of breath and chest pain. A review of Patient 7s primary care physician (MD 7) notes from an office visit on 1/30/2025, indicated that Patient 7 denies any chest pain, edema, or dyspnea (shortness of breath). The documented also indicated that that MD 7 discussed risk factors that can lead to heart disease, and suggested weight loss and exercise program. The document indicated that Patient 7 was not on any diuretic therapy. During an interview on 3/13/2025 at 11:39 am, the office coordinator (OC 1) for Patient 7s primary care Physician (MD7) stated that the patient was recently in on 1/30/2025 and July of 2024. OC 1 stated that there is no record of heart failure or heart disease in their records. OC 1 stated that the office and MD 7 were not informed that Patient 7 was on hospice care. OC 1 stated there was no attempt by HA to contact them to obtain any medical information about Patient 7. During a concurrent interview and record review of Patient 7s medical record, DPCSD stated that the HA did not have any records or diagnostic results to support Patient 7s diagnosis of terminal heart condition. DPCSD stated that the MD 7 was not contacted for consultation or information regarding Patient 7s health status. DPCSD stated that Patient 7 was not on any diuretic therapy. DPCSD stated she wasnt sure if Patient 7 met the LCD guidelines, that it would take a few months of the patient being under hospice care to determine if they are really hospice eligible. During an interview on 3/13/2025 at 1:40pm, Medical Director (MD1) stated that when he determines patients eligibility for hospice, he uses information from discharge papers or medical records, if available, but the more important information was from what the patient or the patients family tell him. He stated that he did not know the LCDs, that he had heard of them but didnt remember them. When asked about specifics of what qualifies a cardiac patient for hospice, he stated that maybe an EF of 50% and the number of medications the patient is on. MD1 stated that you can not determine a patients EF by looking at the patient that it requires specialized testing to find out. During an interview on 3/14/2025 at 12:22 pm, DPCSD stated that when determining eligibility documentation is important because sometimes patients are not very knowledgeable about their medical conditions or can get confused about them. Documentation such as a history and physical would have important information such as detailed information about the patients medical condition including diagnosis, lab test, surgical history. DPCSD stated that Medicare guidelines for eligibility should be used (LCDs) and that the reason for determining eligibility was to know if they should qualify for hospice services or not. DPCSD stated that sometimes you cannot determine if a patient is eligible for hospice services until after you admit them and then services them for a few months to see if they decline or not. A review of the facilitys policy titled, ";Admission Criteria and Process," dated April 2020, indicated that, ";the patient must have a life limiting illness with a life expectance of six months or less, as determined by the attending physician and hospice Medical Director, utilizing standard clinical prognosis criteria developed by LCD (local coverage determination guidelines)." A review of the National Government Services Local Coverage Determination (LCD) for heart disease indicated that patients that would be considered to be in the terminal stage of heart disease (life expectancy of six months or less meet if they meet the criteria of, ";1. At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease or are patients who are either not candidates for surgical procedures or who decline those procedures. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease, and 2. Patients with congestive heart failure or angina(chest pain caused by reduced blood flow to the heart) should meet the criteria for the New York Heart Association (NYHA) Class IV. (Class IV patients with heart disease have an inability to carry on any physical activity. Symptoms of heart failure or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.) Significant congestive heart failure may be documented by an ejection fraction of less than or equal to 20%." A review of the National Government Services Local Coverage Determination (LCD) for Dementia due to Alzheimers Disease and Related Disorders indicated that patients that would be considered to be in the terminal stage dementia (life expectancy of six months or less) if they should show all the following characteristics: Stage seven or beyond according to the Functional Assessment Staging Scale; Unable to ambulate without assistance; Unable to dress without assistance; Unable to bathe without assistance; Urinary and fecal incontinence, intermittent or constant. Patients should have had one the following within the past 12 months: Aspiration pneumonia(occurs when food or liquid is breathed into the airways or lungs); Pyelonephritis(infection where one or both kidneys become infected.); Septicemia(a severe infection that occurs when bacteria enter the bloodstream and spread); Decubitus ulcers (pressure wounds), multiple, stage 3-4; Fever, recurrent after antibiotics; Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin(test measures the amount of this protein in the clear liquid portion of the blood) < 2.5 gm. a. A review of Patient 1s Patient Intake form (Face sheet- a document of a patients personal information such as diagnoses, date of birth, address, etc.) indicated that they are a 66-year-old male with a Start of Care (SOC) date of 2/23/2025. Patient 1 had a primary terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where the heart's arteries are narrowed by plaque buildup, leading to chest pain of an unspecified type which is a symptom of coronary artery disease). A review of Patient 1s initial physicians Certification of Terminal Illness (CTI), dated 2/23/2025 to 5/23/2025 and completed by Medical Director (MD1), indicated that Patient 1 had a primary terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, and has a life expectancy of six months or less, if the terminal illness runs its normal course. MD1 documented that patient was seen and evaluated on 8/26/2024, per patient report patient has multiple hospitalizations over the past year due to worsening atherosclerosis. Patient now has poor prognosis, and no further curative treatments are possible. Patient 1's electronic medical record was reviewed; no documentation was found to support that Patient 1 had multiple hospitalizations over the past year. A review of Patient 1s History and Physical (H&P-a document that describes a persons medical history) from a visit to an emergency department (ER), dated 9/1/2022, indicated that Patient 1 had a past medical history of diabetes mellitus (disease where too much sugar is in the blood which can lead to serious health problems), hypertension (high blood pressure), and stroke (damage to the brain from interruption of its blood supply). Assessment of Patient 1s heart indicated that that had a regular rate and rhythm. An electrocardiogram (EKG-a non-invasive test that records the electrical activity of the heart that can be used to diagnose heart conditions such as irregular heartbeats, heart attacks, heart failure and assess the overall health of the heart) test was preformed and came back normal. No blood tests to test for cholesterol (fat levels in blood that can cause atherosclerotic heart disease and stroke) were completed during Patient 1s ER visit. b. A review of Patient 2s Face sheet indicated a SOC date of 3/1/2025. Patient 2 had a primary terminal diagnosis of atherosclerotic heart disease of native coronary artery with refractory angina pectoris. A review of Patient 2s initial CTI, dated 3/1/2025 to 5/29/2025 and completed by MD1, indicated that Patient 2 had a primary terminal diagnosis of atherosclerotic heart disease of native coronary artery with refractory angina pectoris and has a life expectancy of six months or less, if the terminal illness runs its normal course. MD1 also documented that Patient 2 also has end stage heart failure, has been optimally treated with diuretics (medications that helps removed excess fluid from the body, ultimately helping the heart pump more efficiently) and vasodilators (medication that opens up blood vessels which improves blood flow). Meets criteria for NYHA IV level (New York Heart Association-functional classification for heart failure. Level IV (4) signifies severe limitations, where symptoms are present even at rest, and any physical activity causes discomfort), ventricular arrhythmias and episodes of syncope 2 times in the last 2-month period, resting tachycardia (fast heartbeat, over 100 beats per minute). During an interview on 3/14/2025, at 11:03 am, DPCSD stated that Patient 2 was a self-referral, she did not have an H&P or any medical documents for the patient that confirm Patient 2s diagnoses. c. A review of Patient 8s Face sheet indicated a SOC date of 2/18/2025. Patient 8 had a primary terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. A review of Patient 8s initial CTI, dated 3/1/2025 to 5/29/2025 and completed by MD1, indicated that Patient 8 had a primary terminal diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris and has a life expectancy of six months or less, if the terminal illness runs its normal course A review of Patient 8s H&P from a previous hospital admission, dated 11/21/2023, indicated that Patient 8 had an ejection fraction (EF-a percentage that measures how much blood the heart pumps out with each beat. Normal: 50% or above. Below 40% may indicate heart failure) of 65%. During an interview on 3/14/2025, at 11:28 am, the DPCSD stated that the only documented medical history for Patient 8 was the H&P from 2023. She stated that Patient 8 was a self-referral, and she did not have a primary care physician. d. A review of Patient 9s Face sheet indicated a SOC date of 3/1/2025. Patient 9 had a primary terminal diagnosis of combined systolic and diastolic congestive heart failure. A review of Patient 9s initial CTI, dated 3/1/2025 to 5/29/2025 and completed by MD1, indicated that Patient 9 had a primary terminal diagnosis of combined systolic and diastolic congestive heart failure, and has a life expectancy of six months or less, if the terminal illness runs its normal course. MD1 also documented that Patient 9 experiences chest tightness and shortness of breath (SOB) which is relieved by sublingual Nitro glycerin (a medication to provide relief from chest pain). During an interview on 3/13/2025, at 11:29 am, Patient 9s primary physician (PP1), stated that she was unaware that Patient 9 was signed up with hospice. PP1 stated that she last saw Patient 9 on 1/21/2025 and her next appoint is in April 2025. PP1 stated that Patient 9 was kind of healthy, and she only has chronic kidney disease. Patient 9s heart is good; she has a heart valve issue, but it is not to the point where she is in heart failure. PP1 stated that in her opinion Patient 9 was not eligible for hospice. During a concurrent record review and interview, on 3/14/2025, at 11:03 am, the Director of Patient care Services Designee (DPCSD), confirmed that they do not have a history and physical (H&P) or any other medical documentation for Patient 9 to confirm diagnoses. DPCSD, also reviewed Patient 9s medication profile and confirmed that Patient 9 is not taking Nitro glycerin. During an interview on 3/13/2025, at 1:40 pm, MD 1 hospice patients that have a diagnosis of atherosclerotic heart disease with angina need an accurate and detailed history such as ischemia (reduced blood flow in the body), ejection fracture, which he said is the most important factor, of below 50% and the number and type of cardiac mediations they are taking. MD1 also stated that an up-to-date H&P is needed to assess patient for hospice qualification because an H&P from 2 or more years ago may no longer be accurate because a persons health can change a lot during that time period.

Based on observation, interview, and record review, the Hospice Agency (HA, agency providing care to terminally ill patients who has six months or less to live) failed to ensure the patient's continued eligibility for hospice services related to the palliation (relief of symptoms and suffering cause by life threatening diseases) and management of the terminal illness and related conditions were re-assessed, for 4 of 14 sampled patients (Patients 3, 4, 5 and 10). This deficient practice resulted in patients remaining on hospice care without assessment and who did not need hospice care and management of terminal illness and not receiving appropriate care services that could affect their quality of life. --- A review of Patient 10s Face sheet indicated that they are a 65-year-old female with a SOC date of 1/26/2024. Patient 10 had a primary terminal diagnosis of hypertensive heart disease with heart failure. A review of Patient 10s Hospice Referral (a formal request for a patient to receive hospice care [a type of care focused on comfort and quality of life for individuals with a life -limiting illness] from a healthcare professional) is signed by the Medical Director (MD1) and dated 1/26/2024. The referral indicated for a hospice evaluation for diagnosis of hypertensive heart disease with heart failure. A review of Patient 10s recertification CTI, dated 1/20/2025 to 3/20/2025 and completed by MD1, indicated that Patient 10 had a primary terminal diagnosis of hypertensive heart disease with heart failure and secondary diagnoses of hypertension (high blood pressure), hyperlipidemia (high cholesterol) and generalized weakness, and has a life expectancy of six months or less, if the terminal illness runs its normal course. MD 1 documented that Patient 10 gets relief for chest tightness and shortness of breath (SOB) with sublingual Nitro Glycerin (a medication to provide relief from chest pain). A review of Patient 10s medication profile indicated that they did not have Nitro Glycerin ordered. During an interview on 3/14/2025, at 11:28am, the DPCSD stated that they do not have any documented medical history for Patient 10 to confirm terminal diagnosis. A review of Patient 3s medical record titled, ";Certificate of Terminal Illness," dated 1/29/2025, for recertification of hospice services for the period of 1/29/2025 to 3/29/2025, indicated that Patient 3 was ";confused most of the time, has shortness of breath of exertion, patient in ambulatory using assistive device (a device such as a walker, cane, wheelchair), requiring maximum assistance with on ADL (activities of daily living – such as bathing, dressing, showering, eating, ) During an observation on 3/11/2025 at 3:15pm, Patient 3 was observed independently getting out of a sofa chair and walking 10 feet to sit in another chair he preferred to sit in. He was observed walking without an assistive device (walker, wheelchair, cane). Patient 3 was asked to remove his jacket so LVN 1 could take his blood pressure. Patient 3 understood and was then observed independently removing his jacket and then putting his jacket back on afterwards. During an interview on 3/11/2025 at 3:45 pm, Patient 3s representative (REP 3) stated that Patient 3 is able to dress, bathe, eat walk independently. REP 3 stated that Patient 3 gets some confusion, but that hes always been that way. During an interview on 3/11/2025 at 3:50 pm, Patient 3 was able answer questions regarding his weight, including how much we weighed, recent weight loss and gains. Patient 1 was observed conversing meaningfully with REP 3 in complete sentences and thoughts. During an interview on 3/14/2025 at 1:40 pm, Medical Director (MD1) stated that for a patient to be eligible for hospice care with a diagnosis of Alzheimers, that the patient should not be able to sit a chair that does not have arm supports, that the patient would fall over. MD1 stated that a patient with Alzheimers on hospice services would have advanced dementia and that would mean the patient would not be able to independently take care of own needs such as bathing and that they would forget everything and gave the example of not recognizing caregivers or family members. MD1 stated that the patient could communicate their needs but that maybe they would forget the words sometimes. MD1 did not know the LCD guidelines to determine eligibility for hospice for patients with Alzheimers Disease. A review of Patient 4s Personal Information document, indicated a Start of Care (SOC) date of 8/2/2024, with a primary diagnosis of atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (a condition where the heart's arteries are narrowed by plaque buildup, leading to chest pain of an unspecified type which is a symptom of coronary artery disease. A review of Patient 4s medical record titled, ";Certificate of Terminal Illness," dated 1/29/2025, for recertification of hospice services for the period of 1/29/2025 to 3/29/2025, indicated that Patient 4 had end stage heart failure (condition that occurs when your heart can't pump enough blood for your body's needs) with a life expectancy of 6 months or less to live. The document also indicated that Patient 3 was experiencing shortness of breath at rest and was not responsive to diuretics(medication that helps the body get rid of extra water) and vasodilators (medication that relaxes blood vessels to help increase blood flow). During an interview on 3/12/2025 at 3:00pm, Patient 4 stated she stated that she did not know the services were for terminally ill patients and that she was not terminally ill. Patient 4 stated that she is unaware of any heart issues and does not suffer from shortness of breath. During an concurrent interview and record review of Patient 4s medical file on 3/13/2025 at 4:30pm, DPCSD stated that the HA does not have any records from the primary care physician or previous care providers to support the diagnoses of ES heart failure for Patient 4. DPCSD also stated that there Patient 4 was not currently of diuretics therapy. A review of Patient 5s Personal Information document, indicated a Start of Care (SOC) date of 8/6/2024, with a primary diagnosis of hypertensive heart failure (heart problems that occur because of high blood pressure that is present over a long time). A review of Patient 5s medical record titled, ";Certificate of Terminal Illness, dated 2/2/2025, for the hospice recertification period of 2/2/2025 to 4/2/2025, indicated that Patient 5 was terminally ill with a life expectancy of 6 months or less to live. The document also indicated that Patient 5 had hypertensive heart disease with heart failure, unresponsive to Lasix (diuretic) therapy, had edema (swelling caused by too much fluid trapped in the bodys tissues), has shortness of breath that results her needing assistance with all ADLs, and that she is in ";poor state of health." The documented indicated that Patient 5 was experiencing unintentional weight loss. A review of Patient 5s medical record titled, ";Discharge Summary," dated 7/9/2023 indicated that the patients left ventricle (left chamber of the heart) was within lower limits of normal function, with an ejection fraction (EF- measures your heart's ability to pump oxygen-rich blood out to your body) of 55-60%. The document also indicated that Patient 5s right ventricle (chamber in the right side of the heart) was normal in function and size. A review of Patient 5s Medication Profile indicated that Patient 5 was not on Lasix therapy, or any diuretic therapy. The document further indicated that Patient 5 was on Ozempic (a drug used for weight management) for weight loss. During an interview on 3/14/2025 at 10:50 am, DPCSD stated that Patient 5s medical record did not have any other contents to support the diagnosis of terminal heart failure. DPCSD stated no other records were requested to support the eligibility for hospice. A review of the facility's policy titled, "Certification of Terminal Illness," dated April 2020, indicated that "tools such as Local Coverage Determinations, along with other supporting documentation," are to be used to determine and document a terminal diagnosis. A review of the facility's policy titled, "Medicare Hospice Benefit," dated April 2020, indicated that the hospice benefit is available to patients that, "meet criteria related to their terminal diagnosis," A review of the National Government Services Local Coverage Determination (LCD) for heart disease indicated that patients that would be considered to be in the terminal stage of heart disease (life expectancy of six months or less meet if they meet the criteria of, ";1. At the time of initial certification or recertification for hospice, the patient is or has been already optimally treated for heart disease or are patients who are either not candidates for surgical procedures or who decline those procedures. (Optimally treated means that patients who are not on vasodilators have a medical reason for refusing these drugs, e.g., hypotension or renal disease, and 2. Patients with congestive heart failure or angina(chest pain caused by reduced blood flow to the heart) should meet the criteria for the New York Heart Association (NYHA) Class IV. (Class IV patients with heart disease have an inability to carry on any physical activity. Symptoms of heart failure or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.) Significant congestive heart failure may be documented by an ejection fraction of less than or equal to 20%." A review of the National Government Services Local Coverage Determination (LCD) for Dementia due to Alzheimers Disease and Related Disorders indicated that patients that would be considered to be in the terminal stage dementia (life expectancy of six months or less) if they should show all the following characteristics: Stage seven or beyond according to the Functional Assessment Staging Scale; Unable to ambulate without assistance; Unable to dress without assistance; Unable to bathe without assistance; Urinary and fecal incontinence, intermittent or constant. Patients should have had one the following within the past 12 months: Aspiration pneumonia(occurs when food or liquid is breathed into the airways or lungs); Pyelonephritis(infection where one or both kidneys become infected.); Septicemia(a severeinfection that occurs when bacteria enter the bloodstream and spread); Decubitus ulcers (pressure wounds), multiple, stage 3-4; Fever, recurrent after antibiotics; Inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous six months or serum albumin(test measures the amount of this protein in the clear liquid portion of the blood) < 2.5 gm.

Upon personnel record review, 1 of 1 applicable (Personnel #4) did not have evidence in the personnel file that the following competency assessment was performed by the aide with a patient: (This standard applies to all Hospice Aides providing care/service who are directly employed by the hospice or through a contractual agreement.) ·(C) Shampoo, sink, tub, and bed Personnel #4: The hospice aide competency form utilized by the agency lists "shampoo (tub, shower, bed)". Therefore, cannot verify competency for shampoo at sink.

Upon client record review, 1 of 2 applicable (Patient #5) did not have evidence that the discharge summary includes all required information. Patient #5 Revoked hospice benefit effective 7/29/22 to seek aggressive treatment. DC Summary did not include patient's significant medical history of malignant neoplasm of bladder, angioplasty with implant and pacemaker.