Every finding on record at Gloria Hospice, Inc.

Observed in Record Review. In 3 of 6 records reviewed, surveyor noted that the psychosocial plan of care goal for funeral planning was not measurable with a specific timeframe for goal attainment. For example, in RR#1, the goal for care plan problem for funeral planning stated Family/PCG will access community resources. In RRDC#1, the goal for care plan problem for funeral planning stated MSW will provide information and assistance on advanced directives, financial and community resources and MSW will provide information and assistance with mortuary planning. In RRDC#4 the goal for care plan problem for alteration in comfort stated keep pain below SIT level for comfort Pain will remain in comfortable level during care. Pt will experience a comfortable, peaceful, and safe death in his/her environment of choice. Pt will have increased comfort/satisfaction from pain /discomfort as exhibited by verbal and non-verbal communications. Pt/Family/PCG will verbalize confidence in the management of patient`s pain. Pt/pcg will verbalize/express understanding of medication /treatment orders and side effects.This was reviewed with the LVN/Office Manager.

Observed in Record Review. In 2 of 6 records reviewed, surveyor noted that the Aide Supervisory visit was not documented every 14 days as required by agency policy and regulation. This was observed in RR#1, there were 27 days since the last supervisory visit was documented, and in RRDC#2 there were 28 days since the last supervisory visit was documented. This was reviewed with the LVN/Office Manager.

Observed in Record Review. In 2 of 2 patient records reviewed, During RR#1 and 2, it was noted lack of information in the patient records on advance directives and the California advance directive requirements and in addition lack of documentation that patients, caregivers, and families were educated on this information. This was discussed with the office manager.

Observed in Record Review. In 2 of 2 patient records reviewed, RR#1 and #2 plan of care goals were not specific or measurable. For example, patient will: have improved thought processing or will be maintained at a baseline level; will consume adequate nutrition; will maintain weight in a desired goal range; will have optimum level of oxygen; patient will participate in activities that reduce BP/cardiac workload, patient will maintain BP within individually acceptable range, patient will maintain weight in desired goal range, patient will consume adequate nutrition, patient displays improved well-being such as baseline levels for pulse, BP, respirations, and relaxed muscle tone or body posture, achievement of airway clearance, independence in self-care activities, improvement in activity intolerance, ventilation/oxygenation adequate to meet self-care needs. This RFI was reviewed with the DPCS designee.

Observed in Record Review. In 1 of 3 patient records reviewed, During RR#3 it was noted during the last benefit period starting the end of November 2024 the PRN frequencies on the POC for the SC and MSW were not changed to reflect the reason for the PRN visits or the number of PRN visits ordered. This was discussed with the DPCS designee.

Observed in Record Review. In 1 of 2 patient records reviewed, During RR#1, it was noted the CHHA was ordered once a week as documented on the IDG frequency section and also on the CHHA assignment form however the POC summary stated the CHHA visits were ordered 3x/week and the CHHA visited the patient twice in the first week in December 2024. This was discussed with the DPCS designee.

Observed in Competency Session. In 8 of 8 HR files reviewed, the organization did not have a written education and training program in emergency management that was based on the prioritized risks identified as part of its hazard vulnerability analysis, the emergency operations plan, communications plan, and policies and procedures. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Competency Session. In 8 of 8 HR files reviewed, the organization did not initially educate and train staff, and individuals providing services under arrangement on the following: education on activation and deactivation of the plan; the communication plan; emergency response policies and procedures; evacuation, shelter-in-place, lockdown, and surge procedures; and obtaining resources and supplies. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Patient Home. In 3 of 3 home visits conducted, the policy on advance directives and the California advance directive requirements were not found in home binders. As well, there was no documentation in the records that patients, caregivers, and families were educated on this information. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Record Review. In 1 of 1 patient records reviewed, the patient was discharged for extended prognosis. However, the Notice of Medicare Non-Coverage was signed on the discharge day in RRDC#2. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Record Review. In 1 of 10 patient records reviewed, initial psychosocial and bereavement assessments were not documented as part of the initial comprehensive assessment in RRDC#6. In RRDC#7 psychosocial, spiritual care and bereavement assessments were not documented. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Patient Home. In 1 of 1 skilled nursing home visits, the clinician failed to conduct a medication evaluation on a follow-up visit despite being asked to do so prior to entering the home at RRHV#1. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Record Review. In 10 of 10 patient records reviewed, where the interdisciplinary group met two or more times the organization failed to update the comprehensive assessment based on changes occurring since the initial assessment. For example, in records RRHV#1, RRHV#2, RRHV#3 the interdisciplinary group did not document patient decline, progress towards desired outcomes and goals, and plans for the next two weeks in meeting notes. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Record Review. In 10 of 10 patient records reviewed, records reviewed, plan of care goals were not specific or measurable. For example, patient will: have improved thought processing or will be maintained at a baseline level; will be aware and oriented if possible, and reality will be maintained at an optimal level; will consume adequate nutrition; will maintain weight in a desired goal range; will describe satisfactory pain control at a level (for example, less than 3 to 4 on a rating scale of 0 to 10); will have optimum level of oxygen; will access community resources. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Record Review. In 10 of 10 patient records reviewed, ordered visit frequencies for nursing, spiritual care and psychosocial disciplines included prn, but did not define the reasons for their use. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Record Review. In 10 of 10 patient records reviewed, there were range orders for oxygen of 2 - 5 lpm, however, defined parameters and indications for adjusting or changing settings were not provided. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Record Review. In 2 of 10 patient records reviewed, the organization provides the patient with care, treatment, or services according to the patient's individualized plan of care. In RRHV#3 a physical therapy evaluation was ordered more than 2 months prior to this survey date, but no documentation was found to indicate that it was done. In RRNHV#1 RN visits were ordered every 14 days but only 8 were documented since admission more than 6 month prior to this survey date, and although ordered for 3 visits/week, no aide visits were documented over a 6-week period. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Competency Session. In 1 of 1 HR files reviewed, the individual providing bereavement services did not possess experience or education in grief or loss counseling which was required in the job description in personnel file HR#6 MSW/BC/VC. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Competency Session. In 1 of 1 home health aide personnel file reviewed, the organization did not provide documentation of at least 12 hours of in-service training during the past 12 months. In HR#5 HHA proof of only 7 months of in-service training was provided. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Tracer Activities. The organization failed to document recruitment activities for volunteers. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Tracer Activities. The organization failed to document the cost savings achieved through use of volunteers for this year. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Tracer Activities. The organization failed to achieve volunteer hours of 5% of total patient care hours because there were no active volunteers. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Tracer Activities. Leaders did not manage implementation of patient care policies and procedures governing the provision of care as evidenced by condition level findingsat §418.52, §418.54, §418.56, §418.64, §418.78, §418.100, §418.102 and §418.104

Observed in Competency Session. In 2 of 8 HR files reviewed, the organization did not ensure that staff were oriented to their job duties. In file HR#1 MD and HR#2 ALT contracted physicians did not receive a description of their job duties as part of orientation. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Competency Session. In 1 of 1 volunteer HR file, competence was not initially assessed and documented as part of orientation in HR#8 VOL. This RFI was reviewed with the Administrator/DPCS Designee. Observed in Competency Session. In 8 of 8 HR files reviewed, the organization’s education and training did not comply with law and regulation. OSHA blood borne pathogen and infection control education was not provided at hire. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Record Review. In 5 of 10 patient records reviewed, the organization did not provide medical findings to support a life expectancy of six months or less if the illness followed its normal trajectory. In RRHV#3, RRDC#3, RRDC#4, RRDC#6, RRDC#7 CTIs and primary diagnoses did not support terminal illnesses, and comorbid diagnoses were missing. This RFI was reviewed with the Administrator/DPCS Designee.

Observed in Record Review. In 1 of 10 patient records reviewed, the certificate of terminal illness was not completed prior to the first day of the third benefit period in record RRNHV#1.

Observed in Record Review. In 6 of 10 patient records, records were not complete and accurate. In RRHV#1, RRHV#2, RRNHV#1, RRNHV#2, RRNHV#3, RRDC#3, RRDC#7 election of benefits/consents, and skilled nursing notes were missing. . The RFI was reviewed with the Administrator/DPCS Designee.

Based on interview and record review the hospice agency (HA) failed to provide clinical visit notes for one of 8 sampled patients (Patients 15). This deficient practice had the potential to result in inability to evaluate the care provided to the patient and compromise patient care. --- Findings: During a review of Patient 15's face sheet (patient's admission information) indicated Patient 15 was admitted to the HA on 4/27/2024 with a primary diagnosis of senile degeneration of the brain (symptoms include memory loss, impaired judgement, and problems with day to day activities). During a review of Patient 15s ";staff assignments" it indicated he had skilled nursing visits two time per week, CHHA visits two times per week, and RN visits 2 times per month. During a review of Patient 15s ";History of HA visits" in the Electronic Medical Record (EMR) there was no documentation of the actual visit. During an interview on 9/25/2024 at 12:45 p.m., with CHHA1, CHHA 1 stated that she has never documented in the electronic medical record (EMR) that the agency used. due to access issues. CHHA1 stated she could not access the EMR. CHHA 1 stated she documented her visits notes using a word document and sends it to the agency office each month. CHHA1 stated she has received no further guidance or help to resolve this charting issue from management at the agency. During an interview om 9/25/2024 at 1:05 p.m., with the Administrator/Director of Nursing (ADM/DON) designee, the ADM/DON designee stated the home visit notes for Patient 15 was not in the EMR and should be. The ADM/DON stated that CHHA 1's access to EMR has not been resolved since almost 6 months when Patient 15 has been admitted for service, ADM/DON designee stated that CHHA1 was documenting on a Word document. During a review of the agencys policy entitled ";Entries into the clinical record", undated, it indicated Documentation into the clinical record will be timely, detailed, accurate, and reflect the care or services provided.

Based on interview and record review, the hospice agency (HA) failed to ensure a completed discharge summary upon discharge for three of 4 sampled discharged patients (Patient 2, Patient 8, and Patient 18). This deficient practice had the potential to result in miscommunication and poor hand-off and can affect the care and services needed in the continuation of care for Patient 2, Patient 8, and Patient 18. --- Findings: b. During a closed record review of Patient 8s face sheet (a document that typically include the patient's name, address, date of birth, insurance information, and emergency contact information), the face sheet indicated a start of care (SOC) date of 12/8/2022, with a terminal diagnosis of chronic obstructive pulmonary disease (COPD-a group of lung diseases that block airflow and make it difficult to breathe). During a review of Patient 8s Discharge (DC) Summary form, the DC summary indicated Patient 8 was discharged from the HA due to extended prognosis (a medical term for predicting the likelihood or expected development of a disease), and hospice service was revoked effective date 9/2/2023. The DC summary was not signed by the documenting nurse. c. During a closed record review of Patient 18s face sheet, the face sheet indicated a SOC date of 2/20/2024, with a terminal diagnosis of COPD. During a review of Patient 18s DC Summary form, the DC summary indicated Patient 18 was discharged from the HA due to extended prognosis, and hospice service was revoked effective date 7/18/2024. The DC summary was not signed by the documenting nurse. During a concurrent interview and record review, on 9/25/2024 at 12:15 p.m. with the Administrator/Director of Nursing Designee (ADM/DON Designee), the ADM/DON Designee reviewed Patient 8 and Patient 18 DC summary forms. The DPCSD stated all patients discharged from hospice care should have a completed discharge summary which includes the signature of the documenting registered nurse. The DPCSD stated and acknowledged Patient 8 and Patient 18s DC summary was not signed by the registered nurse and therefore not complete. During a review of the agency's policy and procedure (P&P) titled, Discharge Summary, revised April 2017, the P&P indicated each patient discharged from a service and from hospice will have a discharge summary filed in the clinical record. Hospice personnel who provide care will complete a discharge summary at the time the discipline is discontinued. a. During a review of Patient 2's ";face sheet" it indicated he was admitted to the hospice agency on 6-16-23, with a primary diagnosis of chronic obstructive pulmonary disease (COPD) is a condition involving constriction of the airways and difficulty or discomfort in breathing. During a review of patient 2s ";staff assignments" it indicated he had skilled nursing visits of once per week During a record review of patient 2s ";discharge summary" with an end of care (EOC) date of 9-2-23, no signature of who prepared the discharge summary was documented. During an interview with the ADM/DON designee on 9-25-24 at 1:05pm, the ADM/DON designee was able to review the discharge summary for patient 2 and acknowledged it was not signed by the RN that did the discharge making it incomplete.

Based on interview and record review, the Hospice Agency (HA) failed to ensure one of 14 sampled patients (Patient 5) was informed of the right to choose their own attending physician. This deficient practice had the potential to result in the patient not provided an opportunity to choose their own attending physician to collaborate with the hospice care team about hospice care and services. --- Findings: A record review of Patient 5s ";Personal Information" indicated a start of care on 3/20/23, with a diagnosis of hypertensive (high blood pressure) heart disease with heart failure. During an observation of the home visit on 8/29/23, at 9:31 a.m., Licensed Vocational Nurse 1 (LVN 1) conducted a home visit at Patient 5s residence. During an interview on 8/29/23, at 9:50 a.m., Patient 5 stated he had a primary care physician, whom he saw in July 2023. Patient 5stated the HA told him he could not see his primary care doctor (MD 6) anymore because he was enrolled in hospice care. During an interview on 8/29/23, at 10:30 a.m., of Patient 5s primary care doctors medical assistant (MA) stated the intake coordinator (IC) called the medical office to inform PCP 1 he could not see the patient anymore because he was enrolled in hospice care. During an interview on 8/30/23, at 2:42 p.m., the Director of Patient Care Services (DPCS) stated patients had the right to have their primary care doctor involved in their care while in hospice care. During a concurrent interview and record review on 8/30/23, at 2:42 p.m., the DPCS reviewed Patient 5s record titled, ";Election of Medicare Hospice Benefit", dated 3/20/23. The record indicated Medical Director 2 (MD 2), a referring doctor, was the elected attending doctor. The DPCS stated the HA was unable to verify if Patient 5s was asked which doctor he wanted as his attending doctor because the documents were signed by Registered Nurse 1, who has never worked at the HA. During an interview on 8/30/23, at 2:52 p.m., the IC stated the nurse who sees the patients for start of care is the one responsible in explaining the patients rights and obtaining signatures for the consents. During a concurrent interview and record review on 8/30/23, at 2:42 p.m., the IC reviewed Patient 5s record titled, ";Election of Medicare Hospice Benefit", dated 3/20/23. The records indicated RN 1 had been the nurse obtaining consents for hospice care. The IC stated she did not know who visited the patient or who had him sign the consents because RN 1, as documented, has never worked at the HA. A record review of the HAs policy and procedure titled, ";Clinical Data Collection Review" undated, indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services." A record review of the HAs policy and procedure titled, ";Admission Criteria and Process" undated, indicated ";(HA) will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician, if any... The patients physician must order and approve the provision of hospice care... The patient must desire hospice services and be aware of the diagnosis and prognosis...".

Based on observation, interview, and record review, the hospice agency failed to ensure the Conditions of Participations for initial and Comprehensive Assessments of Patients was met as followed: --- 1. The hospice agency staff failed to conduct and document comprehensive assessment identifying the need for hospice care and services for ten of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). These patients did not have life expectancy of six months or less, and had no documentation for physical, psychosocial, emotional, or spiritual care. (Refer to L 522). 2. The hospice agency failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after hospice election, for eight of fourteen sample selected patients (Patient 1, Patient 2, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14). (Refer to L 523). 3. The hospice staff failed to review the patient's current medications and update the medication profiles for two of fourteen sample selected patients (Patient 5 and Patient 12). The patients were at risk for medication errors and adverse drug reactions. (Refer to L 530). 4. The hospice agency failed to conduct or attempt to conduct a bereavement (the state of having experienced the loss of a loved one) assessment to provide bereavement counseling in accordance with the patient/family's needs that focused on the social, spiritual, and cultural factors that may affect the ability of the family and other individuals involved in the care, to cope with the patients death, for five of fourteen sample selected patients (Patient 8, Patient 9, Patient 10, Patient 12, and Patient 14),(Refer to L 531). 5. The hospice agency failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for ten of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14). (Refer to L 533). The cumulative effect of these systemic practices resulted in the hospice agency admitting patients who did not meet admission criteria and did not qualify for the Medicare hospice benefit.

Based on interview and record review the Hospice Agency (HA) staff failed to conduct and accurate comprehensive assessment that reflected the patient's current health status and had identify patients' need for hospice care and services, related to hospice eligibility and management of terminal illness, for ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, and Patient 12). This deficient practice resulted in the patients' information necessary to develop the plan of care related to terminal illness and related conditions were not assessed accurately for the certification to receive the hospice benefits. --- Findings: A record review of Patient 1s ";Personal Information" indicated a start of care on 7/5/23, with a diagnosis of chronic obstructive pulmonary disease (a lung condition). During a concurrent interview and record review on 8/30/23, at 12:11 p.m., the Director of Nursing (DON), reviewed Patient 1s record titled, ";Comprehensive Nursing Assessment", dated 7/5/23. The record indicated Patient 1 was eligible for hospice services because the patient had a poor response to bronchodilators (medications used to open the airways in the lungs), he had respiratory failure, his oxygen saturation levels (percentage of oxygen in the blood) were less than or equal to 88%, and he was experiencing unintentional progressive weight loss greater than or equal to 10% of his body weight over the last six months. Further review of the record indicated, Registered Nurse 1 (RN 1) completed the initial comprehensive assessment on 7/5/23. The DON was asked where the information was obtained to determine the criteria for hospice care, the DON stated, ";Im guessing from the nurse assessment." During an interview on 8/30/23, at 12:11 p.m., RN 1 stated she did not do any of the initial comprehensive assessments for the HA. RN 1 stated she was not employed at the HA, has not signed any employment documents, and was shocked the HA was using her name in patients documents. RN 1 stated she did not know Patient 1. During an interview on 8/30/23, at 2:08 p.m., the DON stated she did not know if Patient 1s initial comprehensive assessment was accurate because she did not know RN 1 was not employed at the HA. The DON stated she did not know who saw Patient 1for the initial comprehensive assessment. A record review of Patient 2s ";Personal Information" indicated a start of care on 6/15/23, with a diagnosis of chronic obstructive pulmonary disease (a lung condition). During a concurrent interview and record review on 8/30/23, at 2:22 p.m., the DON, reviewed Patient 2s record titled, ";Comprehensive Nursing Assessment", dated 6/16/23, indicated Patient 2 was eligible for hospice services because the patient had a poor response to bronchodilators, he had respiratory failure, and his oxygen saturation levels were less than or equal to 88%. Further review of the record indicated Registered Nurse 1 (RN 1) performed the initial comprehensive assessment on 6/16/23. The DON stated she did not know if Patient 2s initial comprehensive assessment was accurate because RN 1 did not work for the HA. The DON stated she did not know if Patient 2s was assessed and who documented the initial comprehensive assessment. A record review of Patient 3s ";Personal Information" indicated a start of care on 3/8/23, with a diagnosis of heart disease. During a concurrent interview and record review on 8/30/23, at 2:27 p.m., the DON, reviewed Patient 3s record titled, ";Re-Cert (recertification) Assessment", dated 3/8/23. The DON stated Patient 3s comprehensive assessment had to be completed, because this was his first admission to hospice care and not a recertification assessment. The DON stated the initial comprehensive assessment was to describe the criteria for admission to hospice, and the ";re-cert" assessment was to describe why patients should continue hospice. Further review of the record indicated RN 1 was the nurse who performed the assessment on 3/8/23. The DON stated she did not know if Patient 3s was seen and who documented the initial comprehensive assessment, because RN 1 did not work at the HA. The HA failed to ensure an accurate initial comprehensive assessment was done for Patient 3. A record review of Patient 4s ";Personal Information" indicated a start of care on 1/27/23, with a diagnosis of chronic obstructive pulmonary disease (a lung condition). During a concurrent interview and record review on 8/30/23, at 2:30 p.m., the DON, reviewed Patient 4's record titled, ";Comprehensive Nursing Assessment", dated 1/27/23. The record indicated the patient was eligible for hospice services because P4 had progression of the condition. Further review of the record indicated Registered Nurse 1 (RN 1) was the nurse who performed the initial comprehensive assessment on 1/27/23. The DON stated she was assuming the assessment was not accurate because RN 1 did not work for the HA and did not see Patient 4. A record review of Patient 5s ";Personal Information" indicated a start of care on 3/20/23, with a diagnosis of hypertensive (high blood pressure) heart disease with heart failure. During an observation of the home visit on 8/29/23 at 9:31 a.m., Licensed Vocational Nurse 1 (LVN 1) performed a nursing visit. During an observation of P5, the patient seated in a sit to stand walker, wheeling himself around the kitchen. Patient 5s has no shortness of breath , without the use of supplemental oxygen. During an observation on 8/29/30, at 9:40 a.m., Patient 5s stated to LVN 1 he used his walker to walk outside every day. During a concurrent observation and interview on 8/29/23, at 9:45 a.m., a portable oxygen tank, oxygen concentrator, and an unopened packet with oxygen tubing was observed in the living room. Patient 5 stated he had never used the oxygen because he didnt need it. During a concurrent interview and record review on 8/30/23, at 2:33 p.m., the DON, reviewed Patient 5s ";Comprehensive Nursing Assessment", dated 3/20/23. The record indicated Patient 5 was eligible for hospice services because Patient 5 was treated for heart disease with diuretics (medications used to get rid of excess water in the body) and vasodilators (medications used to treat high blood pressure) and he met the NYHA (New York Heart Association) class IV (4) level (unable to carry out any physical activity without discomfort and are tired and short of breath even at rest). Further review of the record indicated Registered Nurse 1 (RN 1) was the nurse who performed the initial comprehensive assessment on 3/20/23. The DON stated she was assuming the assessment was not accurate because RN 1 did not work for the HA and did not see the patient. The DON stated she did not know who documented and conduct the initial assessment Patient 5. A review of Patient 8s medical record form titled ";Patient Information" indicated a start of care date of 12/8/2022 with diagnoses including chronic obstructive pulmonary disease (COPD – difficulty breathing). A review of Patient 8s ";Comprehensive Nursing Assessment" dated 12/8/2022, indicated ";signed by (Intake Coordinator – IC) (ADMN), to close note on behalf of staff assigned, Date 12/10/2022." The patient's Comprehensive Nursing Assessment indicated no other staff name was on form. A review of Patient 8s medical form titled, ";Re-Cert Assessment" dated 6/6//2023, indicated it was electronically signed by RN1. A review of Patient 9s ";Patient Information" indicated a start of care date of 5/15/2023 with diagnoses including Alzheimers Disease (degenerative brain tissue – memory loss). It also indicated Nurse Practitioner 1 (NP1) was the ";referring/attending/patient choice". A review of Patient 9s ";Physicians Certification for Hospice Benefit – Statement for first 90-day period" dated from 5/15/2023 to 8/12/2023, indicated NP1s name was documented on ";Physician Name". It also indicated the IC signed under ";Signature on file/verified by (IC)." Lastly, form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice..." A review of Patient 9s ";Comprehensive Nursing Assessment" dated 5/15/2023, indicated sections ";Wt (lbs); MAC (cm)" and ";Nature & Condition of Terminal Illness/LCD eligibility" were left blank. It also indicated NP1 signed the form. NP1 was called on 8/29/2023, at 1:28 p.m., to number listed the HAs employee list, with no answer. Message with call back number left. During an interview on 8/30/2023, at 10:11 a.m. with the DON, the DON was requested to call NP1, to speak with her. DON stated that NP1 was going to be unavailable all day due to her work schedule. NP1 was called on 8/30/2023, at 12:55 p.m., to number listed the HAs employee list, with no answer. Message with call back number left. A review of Patient 10s ";Patient Information" indicated a start of care date of 1/27/2023 with diagnoses including end stage heart failure (progressive heart failure). It also indicated Medical Doctor 3 (MD3) was the referring MD. During a joint home visit on 8/29/2023 at 10:40 a.m. with License Vocational Nurse 1 (LVN1) to Patient 10s home, LVN1 stated that sometimes he is unable to see the patient because he is not at home. LVN1 stated that patient attends an adult day care center. Patient 10 was observed alert, ambulated using a walker. Patient 10 stated that he had not used the oxygen provided by the HA because he does not get short of breath (SOB). Patient 10 stated that he attends an adult day care center where he does ";mind and physical exercise". the patient stated that he performs all his activities of daily living (ADL – activities of daily living, essential and routine tasks), but he does not shower by himself. Patient 10 stated that he had a primary physician (MD3) since 2007 but has not seen her because he has been in either hospice or home health since then. Patient 10 stated that he has never been told that he had six months or less to live. Patient 10 stated a marketer (MK) told him that there were two types of hospice services, one for those who are bedridden and those who are able to attend adult day care centers. During a phone interview on 8/29/2023 at 12:51 p.m. with MD3s nurse (MDN) stated, they received a call from Patient 10's son on 12/2022, stating that the patient was receiving hospice services. MDN stated that Patient 10 was seen by MD3 from 2010 – 2022. MDN stated that MD3 did not refer the patient to hospice. A review of Patient 11's ";Patient Information" indicated a start of care date of 7/12/2023 and an end of care date of 7/24/2023 with diagnoses including Alzheimers Disease (degenerative brain tissue – memory loss). A review of Patient 11 s ";Comprehensive Nursing Assessment" dated 7/12/2023, indicated it was signed by RN1. A review of Patient 12's ";Patient Information" indicated a start of care date of 2/17/2023 with diagnoses including cerebrovascular disease (stroke). It also indicated Medical Doctor 1 (MD1) was listed under ";referring/attending..." During a concurrent interview and record on 8/30/2023 at 3 p.m. with Director of Nurses (DON) of P12 medical record form titled ";Comprehensive Nursing Assessment" dated 2/21/2023, the DON stated did not complete that form. DON stated that she changed her Electronic Medical Record (EMR) password ";sometime in March" because she noticed her name on other forms. DON stated that she does not know who documented the assessment and who electronically signed it. DON stated that she did not share her EMR logging information with anyone. During a joint home visit on 8/29/2023 at 11:40 a.m. with LVN1 to P12s home, P12 noted laying supine in hospital bed, awake working on a crossword puzzle. P12 noted not moving left arm, P12 signed consent for home visit with right hand. Care Giver 1 (CG1) stated that Patient 12 had a primary physician (MD5), the same physician since 2001, which she saw earlier this month. CG1 stated that she assists P12 onto her wheelchair and they both take the public bus to see MD5. CG1 stated that MD5 has not told them Patient 12 had six months or less to live. CG1 stated that she was referred by a nurse (RN4) and was told that hospice was for patient who are bedridden, unable to see primary physician by themselves, and that hospice provided supplies. CG1 stated that she switched patient from home health to hospice because Patient 12 needed the hospital bed. CG1 stated that the bed is a rental, and that Medicare covers it through hospice. During a telephone interview on 8/29/2023 at 12:12 p.m. with Patient 12's primary physician (MD5), MD5 stated the patient has been his patient for many years and just saw her this month. MD5 stated that she is not a hospice candidate and should not be receiving hospice services. MD5 stated the patient is not dying. MD5 stated that hospice is the number one fraud in the United States of America. MD5 stated that the law says that anyone can sign up, any human being. MD5 stated that this is fraud, and it has nothing to do with medicine, she is not dying, and she should not be in hospice. During an interview on 8/28/2023, at 3p.m., with the DON stated, RN1 was the DON designee while interviewing for the entrance conference. During an interview on 8/30/2023, at 3:35 p.m., with the Administrator (ADM), the ADM stated that RN1 emailed him her nursing credentials, but that she never worked for the HA. ADM stated that he is the one that issues all the employees their paychecks, and that RN1 never received a paycheck from the HA. ADM also stated that the IC was the only person who was able to provide EMR access to the HAs employees. ADM stated that he was not familiar with the EMR the HA uses. A record review of the HAs ";Organizational Chart" undated, indicated the RN1 was listed under ";DPCS (Director of Patient Care Services) Designee". A record review of the HAs policy and procedure titled, ";Initial Assessment" undated, indicated ";An initial assessment will be performed by a registered nurse within 48 ours after election of hospice care...the initial assessment will be included as a part of the comprehensive assessment". A record review of the HAs policy and procedure titled, ";Comprehensive Assessment" undated, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented...including at least... nature and condition causing admission... Past medical and surgical care... The assessment should determine: probable prognosis of six (6) months or less..." A record review of the HAs policy and procedure titled, ";Clinical Data Collection Review" undated, indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services." A record review of the HAs policy and procedure titled, ";Admission Criteria and Process" undated, indicated ";The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determinations (LCDs). (HA) will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician, if any... The patients physician must order and approve the provision of hospice care... The patient must desire hospice services and be aware of the diagnosis and prognosis...".

Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after hospice election for eight of fourteen sampled patients (Patient 1, Patient 2, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14). This failure has the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- Findings: A review of Patient 1s ";Personal Information" indicated a start of care on 7/5/23, with a diagnosis of chronic obstructive pulmonary disease (a lung condition). During an interview on 8/30/23, at 12:11 p.m., Registered Nurse 1 (RN 1) stated she did not do any of the initial comprehensive assessments for the HA. RN 1 stated she was not employed by the HA, has not signed any employment documents, and was shocked the HA was using her name in patients documents. RN 1 stated she did not know Patient 1. During an interview on 8/30/23, at 2:08 p.m., the DON stated she did not know RN 1 was not employed at the HA. During an interview on 8/30/23, at 2:57 p.m., the Director of Nursing (DON) stated the IDG group was supposed to meet within 5 days of the start of care to discuss the comprehensive assessment and develop a plan of care for the patients. During a concurrent interview and record review on 8/30/23, at 3:30 p.m., of Patient 1s record titled, ";POC/IDG", dated 7/5/23, indicated Registered Nurse 1 (RN 1) documented the plan of care. The DON stated the doctor (MD), registered nurse (RN), and spiritual counselor (SC) were not involved in the IDG meeting because their signatures were not in the document. The signature indicated they provided input and participation in the discussion of the comprehensive assessment and care planning. The DON stated she did not know if the needs of the patient were met because there was no documentation to show the needs were discussed. The HA failed to ensure the IDG team met to discuss the comprehensive assessment and develop the plan of care. A review of Patient 2s ";Personal Information" indicated a start of care on 6/15/23, with a diagnosis of chronic obstructive pulmonary disease (a lung condition). During a concurrent interview and record review on 8/30/23, at 3:33 p.m., of Patient 2s record titled, ";POC/IDG", dated 6/16/23. The record indicated RN 1 documented the plan of care. The DON stated the MD, RN, medical social worker (MSW), and SC did not participate in the discussion of the comprehensive assessment. The DON stated she wouldnt know if the needs of the patient were discussed because there was no documentation to show it. The HA failed to ensure the IDG team met to discuss the comprehensive assessment and develop the plan of care. A review of Patient 8s medical record form titled ";Patient Information" indicated a start of care date of 12/8/2022 with diagnoses including chronic obstructive pulmonary disease (COPD – difficulty breathing). A review of Patient 8s Electronic Medical Record (EMR) form titled ";POC/IDG Review" dated 12/8/2022, indicated the RN signature and Chaplain signatures were left blank. During a concurrent interview and record review on 8/30/2023 at 2:50 p.m. with the Director of Nurses (DON) of Patient 8s EMR medical record form titled ";POC/IDG Review – (As of 12/8/2022, Cert#1)" dated 12/8/2022, indicated sections ";RN signature and Chaplain signature" were left blank. DON stated the signatures would validate the members attendance. DON stated that there was a possibility that the patient would not receive the plan of care ordered. A review of Patient 9s medical record form titled ";Patient Information" indicated a start of care date of 5/15/2023 with diagnoses including Alzheimers Disease (degenerative brain tissue – memory loss). It also indicated Nurse Practitioner 1 (NP1) was the ";referring/attending/patient choice". A review of Patient 9s EMR form titled ";POC/IDG Review" dated 5/15/2023, indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. It also indicated ";Alert! Complete level of care (LOC) or frequency of visits or staff assigned information prior to signing". During a concurrent interview and record review on 8/30/2023 at 2:53 p.m. with the DON of Patient 9s EMR medical record form titled ";POC/IDG Review – (As of 5/15/2023, Cert#1)" dated 5/15/2023, indicated ";RN signature, MSW signature, MD signature and Chaplain signature" were left blank. DON stated that she is not aware of the patient received the services in the plan of care. DON stated that the member signatures indicated that they were present and that they agreed with the patients plan of care. Form also indicated ";Alert! Complete level of care (LOC) or frequency of visits or staff assigned information prior to signing". DON stated Patient 9s level of care and visit frequency were not documented and that this can cause confusion to the patient and staff. A review of Patient 10's ";Patient Information" indicated a start of care date of 1/27/2023 with diagnoses including end stage heart failure (progressive heart failure). It also indicated MD3 was the referring MD. A review of Patient 10's ";POC /IDG Review" dated 1/27/2023, indicated RN signature, and Chaplain signatures were left blank. During a concurrent interview and record review on 8/30/2023 at 2:56 p.m., with the DON of Patient 10's EMR form titled ";POC/IDG Review – (As of 1/27/2023, Cert#1)" dated 1/27/2023, indicated ";RN signature and Chaplain signature" were left blank. DON stated that she was not aware if the patient received the services in the plan of care. DON stated that the members were supposed to sign the form to validate their attendance and agree with the plan of care for the patient. A review of Patient 12's ";Patient Information" indicated a start of care date of 2/17/2023 with diagnoses including cerebrovascular disease (stroke). It also indicated MD1 was listed under ";referring/attending..." A review of Patient 12's EMR form titled ";POC/ IDG Review" dated 2/17/2023, indicated RN signature, and Chaplain signatures were left blank. During a concurrent interview and record review on 8/30/2023, at 2:57 p.m., with the DON of Patient 12's EMR medical record form titled ";POC/IDG Review – (As of 2/17/2023, Cert#1)" dated 2/17/2023, indicated ";RN signature and Chaplain signature" were left blank. DON stated that if the form was not signed by the indicated member, then that member was not present at the meeting. A review of Patient13's medical record form titled ";Patient Information" indicated a start of care date of 2/24/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with angina pectoris (decrease blood flow to the heart). A review of Patient13's EMR form titled ";POC/ IDG Review" dated 2/24/2023, indicated RN signature, and Chaplain signatures were left blank. During a concurrent interview and record review on 8/30/2023, at 2:59 p.m., with the DON of Patient13's EMR titled ";POC/IDG Review – (As of 2/24/2023, Cert#1)" dated 2/24/2023, indicated ";RN signature and Chaplain signature" were left blank. DON stated that there were no signatures in those sections and was unsure if either of them attended the IDG meeting. A review of Patient 14 medical record form titled ";Patient Information" indicated a start of care date of 2/21/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with angina pectoris (decrease blood flow to the heart). A review of Patient 14s ";POC/ IDG Review" dated 2/21/2023, indicated RN signature, and Chaplain signatures were left blank. During a concurrent interview and record review on 8/30/2023 at 3 p.m., with the DON of Patient 14s EMR ";POC/IDG Review – (As of 2/21/2023, Cert#1)" dated 2/21/2023, indicated ";RN signature and Chaplain signature" were left blank. DON stated that she is not aware if the patient received the services in the plan of care. DON stated that the RN and Chaplain did not attend the IDG meeting. During an interview on 8/28/2023, at 3 p.m., with the Director of Nurses (DON) stated IDG meeting should be initially completed within 5 days of admission. DON stated that the meetings are held by the members, MD, MSW, RN, and Chaplain to go over the patients condition and to determine if they meet criteria for hospice. DON stated that all members sign through their EMR, and that their signatures indicate that they were present in the meeting. DON stated that their signatures validate their attendance. DON stated that each discipline writes their own narrative. During an interview on 8/30/2023 at 3:27 p.m., with the DON stated that she does not attend the IDG meetings. DON stated that she assumed the visiting RN attended. A review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" undated, indicated ";The interdisciplinary group will meet on a regular basis... Referrals and admissions will be reviewed to establish appropriateness for hospice care." A review of the HAs policy and procedure titled, ";The Plan of Care" undated, indicated ";A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care...The plan of care will be reviewed prior to care being delivered. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care." A review of the HAs policy and procedure titled, ";Physician Services – Medical Director" undated, indicated ";The duties and responsibilities of the Medical Director will include, but not be limited to, the following: establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care..." A review of the HAs policy and procedure titled, ";Clinical Data Collection Review" undated, indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services." A review of the HAs policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" undated, indicated ";The hospice interdisciplinary team/group members will include, at a minimum: Physician, Registered Nurse, Social Worker, Pastoral... The interdisciplinary group will: participate in the establishment of the plan of care..."

Based on observation, interview and record review, the Hospice Agency (HA) staff failed to review all medications the patients were taking and update their medication profiles with the currently used medications for two of fourteen sample patients (Patient 5 and Patient 12). This deficient practice had the potential to put the patient at risk for medication errors and adverse drug reactions. --- Findings: A review of Patient 5s ";Personal Information" indicated a start of care on 3/20/23, with a diagnosis of hypertensive (high blood pressure) heart disease with heart failure. During a concurrent observation and interview of Patient 5's medications during the home visit on 8/29/23, at 10 a.m., with Licensed Vocational Nurse 1 (LVN 1), disclosed the following medications: Glucosamine (a supplement), dose unknown. Vitamin D3 (a supplement) 5000 IU (international units, unit of measurement). Rosuvastatin (to treat high cholesterol levels) 20 mg (milligrams, unit of measurement) 20 mg. Aspirin (a blood thinner) 81 mg. Omeprazole (to treat acid reflux) 20 mg. Dorzolamide (to treat glaucoma, an eye condition) HCL (hydrochloride) 2%. LVN 1 stated these medications were not in Patient 5's record titled, ";Current Treatment/Medication/DME List". The following medications were listed on Patient 5s record titled, ";Current Treatment/Medication/DME List" but not observed at the home: Atorvastatin Calcium (to treat elevated of fat in the blood) 20 mg (milligram, unit of measurement) tablet. Memantine hydrochloride (to treat dementia) 10 mg. A review of Patient 12s medical record form titled ";Patient Information" indicated a start of care date of 2/17/2023 with diagnoses including cerebrovascular disease (stroke). A review of Patient12's medical record form titled ";Current Treatment/Medication/DME List" indicated Vitamin D3, Linzess (stool softener medication) and Xeralto (blood thinner medication) were not documented. It also indicated ";Losartan Potassium (blood pressure medication) 100 milligrams (mg) one tab oral once a day". During a joint home visit on 8/29/2023,at 11:40 a.m., with License Vocational Nurse 1 (LVN1) at Patient 12s home, it was observed LVN1 while reconciliating the patient's medications bottle to the HAs medication list, stated he completes the medication reconciliation ";every few visits". LVN1 stated the medication list needs to be reconciled to assure all the medications are consistent with the doctors orders. LVN1 stated that he does not know where all the patient's medications are and would have to ask the patient's Care Giver 1 (CG1). During a concurrent interview and observation on 8/29/2023, at 12 p.m., with CG1, stated that Patient 12s Losartan was supposed to be 50 mg instead of 100mg daily, as prescribed by patient's Medical Doctor 5 (MD5). CG1 stated that she keeps the Losartan separated from the rest of the medications because she needs to cut it in half. Patient 12s medication bottle indicated Losartan Potassium 100mg take one tablet by mouth every day for hypertension ordered by MD1 on 7/12/2023 and last filled on 8/18/2023. During an interview on 8/28/2023, at 3 p.m., with the Director of Nurses (DON), stated that the medication list is reconciled and documented on admission. DON stated the admitting RN assesses the medications and goes over the list with MD. DON stated the medication list should be reconciled upon admission, changes if any, and at every visit. A review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" undated, indicated ";An interdisciplinary group meeting plan of care update form will be used... It will note changes, responses to treatment and progress toward outcomes, which may include: plan for changes in treatments or procedures." A review of the HAs policy and procedure titled, ";Comprehensive Assessment" undated, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented...including at least... review of current and related past medications..." A review of the HAs policy and procedure titled, ";Clinical Data Collection Review" undated, indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services." A review of the HAs policy and procedure titled, ";Medication Profile" undated, indicated ";Medication profiles will be updated for each change to reflect current medications and new and/or discontinued medications. A comparison of the medications ordered for the patient while under the organizations care will be made to those on the list. Visiting personnel will do medication reconciliation on every visit."

Based on interview and record review the Hospice Agency (HA) failed to conduct or attempt to conduct a bereavement assessment to provide bereavement counseling in accordance with the patient/family's needs for five of fourteen sample selected patients (Patient 8, Patient 9, Patient 10, Patient 12, and Patient 14). This deficient practice has the potential for the patient/family not being provided social, spiritual, and cultural support related to the patient's death. --- Findings: A review of Patient 8s medical record form titled ";Patient Information" indicated a start of care date of 12/8/2022 with diagnoses including chronic obstructive pulmonary disease (COPD – difficulty breathing). A review of 8s medical record form titled ";Current Treatment/Medication/DME List" indicated ";Social Worker: to evaluate within 5 days of admission... - Spiritual Counselor: to evaluate within 5 days of admission..." A record review on 8/29/2023, at 4:46 p.m., of 8s Electronic Medical Record (EMR) ";History of Bereavement Assessment" indicated there were no assessment documented. During a concurrent interview and record review on 8/30/2023 at 3:22 p.m., with the Director of Nurses (DON) of Patient 8s EMR medical record, the DON stated that there was nothing documented that P8 refused to have a bereavement assessment. A review of Patient 9's medical record form titled ";Patient Information" indicated a start of care date of 5/15/2023 with diagnoses including Alzheimers Disease (degenerative brain tissue – memory loss). A review of Patient 9 medical record form titled ";Current Treatment/Medication/DME List" indicated ";Social Worker: to evaluate within 5 days of admission... - Spiritual Counselor: to evaluate within 5 days of admission..." A record review on 8/29/2023 at 4:16 p.m. of Patient 9s EMR medical record form titled ";History of Bereavement Assessment" indicated there were no assessment documented. During a concurrent interview and record review on 8/30/2023 at 3:22 p.m., with the Director of Nurses (DON) of Patient 9s EMR medical record, the DON stated there was nothing documented indicating the patient refused to have a bereavement assessment. A review of Patient 10 medical record form titled ";Patient Information" indicated a start of care date of 1/27/2023 with diagnoses including end stage heart failure (progressive heart failure). A review of Patient 10 medical record form titled ";Current Treatment/Medication/DME List" indicated ";Social Worker: to evaluate within 5 days of admission... - Spiritual Counselor: to evaluate within 5 days of admission..." A record review on 8/29/2023 at 4:47 p.m., of Patient 10s EMR form titled ";History of Bereavement Assessment" indicated there were no assessment documented. During a concurrent interview and record review on 8/30/2023 at 3:23 p.m., with the Director of Nurses (DON) of Patient 10s EMR the DON stated there was nothing documented indicating Patient 10 refused to have a bereavement assessment. A review of Patient 12 medical record form titled ";Patient Information" indicated a start of care date of 2/17/2023 with diagnoses including cerebrovascular disease (stroke). It also indicated MD1 was listed under ";referring/attending." A review of Patient 12 medical record form titled ";Current Treatment/Medication/DME List" indicated ";Social Worker: to evaluate within 5 days of admission... - Spiritual Counselor: to evaluate within 5 days of admission..." A record review on 8/29/2023, at 4:47 p.m., of Patient 12s EMR medical record form titled ";History of Bereavement Assessment" indicated there were no assessment documented. During a concurrent interview and record review on 8/30/2023 at 3:24 p.m., with the Director of Nurses (DON) of Patient 12's EMR medical record, the DON stated that there was nothing documented to indicate the patient refused to have a bereavement assessment. A review of Patient 14 medical record form titled ";Patient Information" indicated a start of care date of 2/21/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with angina pectoris (decrease blood flow to the heart). A record review on 8/29/2023 at 4:48 p.m., of Patient 14's EMR medical record form titled ";History of Bereavement Assessment" indicated there were no assessment documented. During a concurrent interview and record review on 8/30/2023 at 3:25 p.m., with the Director of Nurses (DON) of Patient 14's EMR, DON stated that there was nothing documented Patient 14 refused to have a bereavement assessment. During an interview on 8/28/2023 at 3 p.m., with the Director of Nurses (DON) stated that initial bereavement assessment should be done within the first 5 days of admission, even if the patient doesnt want to have it done. DON stated that even if the patient refuses the assessment, staff ";still must document something". A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" undated, indicated ";The patients plan of care will be updated... social, cultural, and physical environments presenting obstacles to effective intervention; integration of alternative therapies into medical regime to assist in effectiveness; and any special needs of the patient". A record review of the HAs policy and procedure titled, ";Comprehensive Assessment" undated, indicated ";During the comprehensive patient assessment, all baseline data and other relevant information will be documented including at least... A bereavement assessment..." A record review of the HAs policy and procedure titled, ";Bereavement Assessment" undated, indicated ";On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment... the Bereavement Coordinator will review the bereavement risk assessment to determine potential needs of the survivors." A record review of the HAs policy and procedure titled, ";Psychosocial Assessment" undated, indicated ";An in-depth psychosocial assessment will be completed by a qualified hospice social worker... If the patient and/or family/caregiver refuses psychosocial visits, patient and family/caregiver need will continue to be assessed on an ongoing basis." A record review of the HAs policy and procedure titled, ";Clinical Data Collection Review" undated, indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse (RN), Medical Social Worker (MSW), Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for ten of fourteen sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14). This deficient practice has the potential for the patients' progress toward desired outcomes, including the patients' response to the care will not be identified, causing delay of treatment, intervention, and management of needs of the terminally ill patients. --- Findings: A record review of Patient 1s ";Personal Information" indicated a start of care on 7/5/23, with a diagnosis of chronic obstructive pulmonary disease (a lung condition). During an interview on 8/30/23, at 12:11 p.m., Registered Nurse 1 (RN 1) stated she did not do any of the initial comprehensive assessments for the HA. RN 1 stated she was not employed by the HA, has not signed any employment documents, and was shocked the HA was using her name in patients documents. RN 1 stated she did not know Patient 1. During an interview on 8/30/23, at 2:08 p.m., the DON stated she did not know RN 1 was not employed by the HA. During an interview on 8/30/23 at 3:23 p.m., the DON stated she did not attend any IDG meetings because she thought the visiting nurse was attending. The DON stated a registered nurse should attend the meeting to report the comprehensive assessment. The DON stated the Intake Coordinator (IC), who was not a registered nurse, was coordinating the IDG meetings. During a concurrent interview and record review on 8/30/23, at 3:30 p.m., the DON reviewed Patient 1 record titled, ";POC/IDG", dated 7/5/23. The record indicated Registered Nurse 1 (RN 1) documented the plan of care. The DON stated the doctor (MD), registered nurse (RN), and spiritual counselor (SC) were not involved in the IDG meeting because their signatures were not in the document. The signature indicated they provided input and participation in the discussion of the comprehensive assessment and care planning. The DON stated she did not know if the needs of the patient were met because there was no documentation to show the needs were discussed. The DON stated there were no additional IDG meetings for Patient 1. The DON stated the next meeting was supposed to be 14 days from 7/5/23. The DON stated it was important for the IDG group to meet so the needs of the patient will be met, there are no delays of care, and the HA could continue to provide care according to the needs of the patient. A record review of Patient 2s ";Personal Information" indicated a start of care on 6/15/23, with a diagnosis of chronic obstructive pulmonary disease (a lung condition). During a concurrent interview and record review on 8/30/23, at 3:33 p.m., the DON reviewed Patient 2's record titled, ";POC/IDG", dated 6/16/23. The record indicated RN 1 documented the plan of care. The DON stated the MD, RN, medical social worker (MSW), and SC did not participate in the discussion of the comprehensive assessment. The DON stated she wouldnt know if the needs of the patient were discussed because there was no documentation to show it. During a concurrent interview and record review on 8/30/23, at 3:34 p.m., of Patient 2s record titled, ";POC/IDG", dated 6/22/23. The record indicated RN 1 documented the plan of care. The DON stated there was no nursing discussion. The nursing discussion was important, so the IDG knows what is going on with the patient, their condition, what their needs are, and if the plan of care is being followed. The DON stated the MD, RN, MSW, and SC did not participate in this IDG because there were no signatures. During a concurrent interview and record review on 8/30/23, at 3:36 p.m., with DON of Patient 2's record titled, ";POC/IDG", dated 7/6/23. The record indicated RN 1 documented the plan of care. The DON stated there was no spiritual and psychosocial discussion documented. The potential outcome of this was the patient's spiritual and psychosocial needs will not be met. The DON stated the MD, RN, MSW, and SC did not participate in the IDG meeting because there were no signatures. Continued review of the records indicated the IDG group did not meet anymore, at least every 15 days to update the patient's comprehensive assessment. A record review of Patient 3s ";Personal Information" indicated a start of care on 3/8/23, with a diagnosis of heart disease. During a concurrent interview and record review on 8/30/23, at 3:37 p.m., with the DON of Patient 3's record titled, ";POC/IDG", dated 5/11/23. The record indicated the DON had documented the plan of care. DON stated there was no spiritual and psychosocial discussion documented. The potential outcome of this was Patient 3 spiritual and psychosocial needs will not be met. The DON stated the MD, RN, MSW, and SC did not participate in the IDG meeting because there were no signatures. During a concurrent interview and record review on 8/30/23, at 3:38 p.m., of Patient 3's record titled, ";POC/IDG" dated 6/8/23, indicated the DON had documented the plan of care. The DON stated the MD, RN, and SC did not participate in the IDG meeting because there were no signatures. The Don stated the potential outcome of this was Patient 3s needs not being met. During a concurrent interview and record review on 8/30/23, at 3:39 p.m., of Patient 3's record titled, ";POC/IDG", dated 6/22/23. The record indicated the DON documented the plan of care. The DON stated there was no nursing discussion. The nursing discussion was important, so the IDG knows what is going on with the patient, their condition, what their needs are, and if the plan of care is being followed. The DON stated the spiritual needs of the patient were not discussed either. The DON stated the MD, RN, and SC did not participate in this IDG because there were no signatures. During a concurrent interview and record review on 8/30/23, at 3:40 p.m., Patient 3 record titled, ";POC/IDG", dated 7/6/23. The record indicated the DON documented the plan of care. The DON stated there was no spiritual discussion, and Patient 3s spiritual needs were not identified. The DON stated the MD, RN, and SC did not participate in this IDG because there were no signatures. Continued review of the records indicated the IDG group did not meet anymore, at least every 15 days to update Patient 3s comprehensive assessment. During a concurrent interview and record review on 8/30/23, at 3:41 p.m., the DON reviewed Patient 4s record titled, ";POC/IDG", dated 5/11/23. The record indicated RN 1 documented the plan of care. The DON stated there was no spiritual discussion, and Patient 4s spiritual needs were not identified. The DON stated there was no psychosocial discussion, and Patient 4s needs were not identified. The DON stated the MD, RN, MSW, and SC did not participate in this IDG because there were no signatures. The needs of the patients were not discussed because there was no signature to validate the discussion documented. During a concurrent interview and record review on 8/30/23, at 3:42 p.m., the DON reviewed Patient 4s record titled, ";POC/IDG", dated 5/25/23. The record indicated RN 1 documented the plan of care. The DON stated the MD, RN, MSW, and SC did not participate in this IDG because there were no signatures. The needs of the patients were not discussed because there was no signature to validate the discussion documented. During a concurrent interview and record review on 8/30/23, at 3:42 p.m., the DON reviewed Patient 4s record titled, ";POC/IDG", dated 6/8/23. The record indicated RN 1 documented the plan of care. The DON stated the MD, RN, and SC did not participate in this IDG because there were no signatures. The needs of the patients were not discussed because there was no signature to validate the discussion documented. During a concurrent interview and record review on 8/30/23, at 3:43 p.m., the DON reviewed Patient 4s record titled, ";POC/IDG", dated 6/22/23. The record indicated RN 1 documented the plan of care. The DON stated the MD, RN, and SC did not participate in this IDG because there were no signatures. The needs of the patients were not discussed because there was no signature to validate the discussion documented. Continued review of the records indicated the IDG group did not meet anymore, at least every 15 days to update Patient 4s comprehensive assessment. A record review of Patient 5s ";Personal Information" indicated a start of care on 3/20/23, with a diagnosis of hypertensive (high blood pressure) heart disease with heart failure. During a concurrent interview and record review on 8/30/23, at 3:44 p.m., the DON reviewed Patient 5s record titled ";POC/IDG" dated 5/11/23. The DON stated there was no psychosocial discussion documented, and patient's needs were not identified. The potential outcome would be patient's needs not being referred to other resources due to not identifying his psychosocial needs. The DON stated the MD, RN, and MSW signatures were missing. The needs of the patients were not discussed because there were no signatures to validate the discussion documented. During a concurrent interview and record review on 8/30/23, at 3:44 p.m., the DON reviewed Patient 5s record titled ";POC/IDG" dated 5/25/23. The DON stated there was no psychosocial discussion documented, and patient's needs were not identified. The potential outcome would be Patient 5 not being referred to other resources due to not identifying his psychosocial needs. The DON stated the MD, RN, and MSW signatures were missing. The needs of the patients were not discussed because there were no signatures to validate the discussion documented. During a concurrent interview and record review on 8/30/23, at 3:45 p.m., the DON reviewed P5s record titled ";POC/IDG" dated 6/8/23. The DON stated the MD and RN signatures were missing. The needs of the patients were not discussed because there were no signatures to validate the discussion documented. During a concurrent interview and record review on 8/30/23, at 3:46 p.m., of Patient 5s record titled ";POC/IDG" dated 7/6/23, DON stated there was no nursing discussion documented, and patient's needs were not identified. The DON stated the MD and RN signatures were missing. The needs of the patients were not discussed because there were no signatures to validate the discussion documented. Continued review of the records indicated the IDG group did not meet anymore, at least every 15 days to update Patient 5s comprehensive assessment. A review of Patient 8s medical record form titled ";Patient Information" indicated a start of care date of 12/8/2022 with diagnoses including chronic obstructive pulmonary disease (COPD – difficulty breathing). A review of Patient 8s medical record form titled ";Current Treatment/Medication/DME List" indicated ";IDT: to review patient status every 14 days and as needed to evaluate changes in patients condition." A review of Patient 8s medical record form titled ";POC (plan of care – individualized patient plan of care describing the type of care and services needed) / IDG (Interdisciplinary group – the team responsible for development and review of the patients plan of care) Review" dated 5/11/2023, indicated there was no discussion input from Spiritual, Psychosocial, and Physician. It also indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. During a concurrent interview and record review on 8/30/2023 at 3 p.m., with the Director of Nurses (DON) of Patient 8s Electronic Medical Record (EMR) medical record form titled ";POC/IDG Review" dated 5/25/2023, indicated there was no discussion input from Psychosocial, and Physician. It also indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. DON stated that the signatures validate the members attendance. DON stated that there was a possibility that the patient would not receive the plan of care ordered. During a concurrent interview and record review on 8/30/2023 at 3:01 p.m., with the DON of Patient 8s EMR medical record form titled ";POC/IDG Review" dated 6/8/2023, there was no discussion input from Spiritual and Physician. It also indicated MD signature, RN signature, and Chaplain signatures were left blank. DON stated that all IDG members needed to participate to go over Patient 8s plan of care. During a concurrent interview and record review on 8/30/2023 at 3:02 p.m. with the DON of Patient 8s EMR medical record form titled ";POC/IDG Review" dated 6/22/2023, indicated there was no discussion input from Psychosocial and Spiritual. It also indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. DON confirmed the record was not filled out. DON stated that if they would have met, their signatures and discussions would be documented. During a concurrent interview and record review on 8/30/2023 at 3:02 p.m. with the DON of Patient 8s EMR medical record form titled ";POC/IDG Review" dated 7/6/2023, indicated there was no discussion input from Spiritual. It also indicated MD signature, RN signature, and Chaplain signatures were left blank. DON confirmed the missed discipline discussions and the members missing signatures. A review of Patient 9s medical record form titled ";Patient Information" indicated a start of care date of 5/15/2023 with diagnoses including Alzheimers Disease (degenerative brain tissue – memory loss). A review of Patient 9s medical record form titled ";Current Treatment/Medication/DME List" indicated ";IDT: to review patient status every 14 days and as needed to evaluate changes in patients condition." During a concurrent interview and record review on 8/30/2023 at 2:52 p.m. with the DON of Patient 9s EMR medical record form titled ";POC/IDG Review – (As of 5/15/2023, Cert#1)" dated 5/15/2023, indicated ";RN signature, MSW signature, MD signature and Chaplain signature" were left blank. DON stated that she is not aware of the patient received the services in the plan of care. DON stated that the member signatures indicated that they were present and that they agreed with the patients plan of care. Form also indicated ";Alert! Complete level of care (LOC) or frequency of visits or staff assigned information prior to signing". During a concurrent interview and record review on 8/30/2023 at 3;04 p.m. with the DON of Patient 9s EMR medical record form titled ";POC/IDG Review" dated 5/25/2023, indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. DON stated sections ";Frequency of visits and plan of care (problem/interventions/goals/status" were left blank. During a concurrent interview and record review on 8/30/2023 at 3:05 p.m., with the DON of Patient 9s EMR medical record form titled ";POC/IDG Review" dated 6/8/2023, indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. It also indicated sections ";Frequency of visits and plan of care (problem/interventions/goals/status" were left blank. DON confirmed the members missing signatures. During a concurrent interview and record review on 8/30/2023 at 3:05 p.m. with the DON of Patient 9s EMR medical record form titled ";POC/IDG Review" dated 6/22/2023, indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. It also indicated sections ";Frequency of visits and plan of care (problem/interventions/goals/status" were left blank. DON confirmed the members missing signatures. During a concurrent interview and record review on 8/30/2023 at 3:06 p.m., with the DON of Patient 9s EMR medical record form titled ";POC/IDG Review" dated 7/6/2023, indicated there was no discussion input from Psychosocial, and Spiritual and the MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. It also indicated sections ";Frequency of visits and plan of care (problem/interventions/goals/status" were left blank. DON stated, ";all of the IDG meeting notes should be completed and signed on the day of the meeting." A review of Patient 10s medical record form titled ";Patient Information" indicated a start of care date of 1/27/2023 with diagnoses including end stage heart failure (progressive heart failure). It also indicated MD3 was the referring MD. A review of Patient 10s medical record form titled ";Current Treatment/Medication/DME List" indicated ";IDT: to review patient status every 14 days and as needed to evaluate changes in patients condition." During a concurrent interview and record review on 8/30/2023 at 2:56 p.m. with the DON of Patient 10s EMR medical record form titled ";POC/IDG Review – (As of 1/27/2023, Cert#1)" dated 1/27/2023, indicated ";RN signature and Chaplain signature" were left blank. DON stated that she is not aware if the patient received the services in the plan of care. DON stated that the member was supposed to sign the form to validate their attendance. During a concurrent interview and record review on 8/30/2023 at 3:07 p.m., with the DON of Patient 10s EMR medical record form titled ";POC/IDG Review" dated 5/25/2023, indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. It also indicated there was no input/discussion from spiritual, psychosocial, and physician. DON confirmed the missed discipline discussions and the members missing signatures. During a concurrent interview and record review on 8/30/2023 at 3:08 p.m. with the DON of Patient 10s EMR medical record form titled ";POC/IDG Review" dated 6/8/2023, indicated MD signature, RN signature, and Chaplain signatures were left blank. DON confirmed the members missing signatures. During a concurrent interview and record review on 8/30/2023 at 3:09 p.m. with the DON of Patient 10s EMR medical record form titled ";POC/IDG Review" dated 6/22/2023, indicated MD signature, RN signature, and Chaplain signatures were left blank. It also indicated there was no input/discussion from spiritual and physician. DON confirmed the missed discipline discussions and the members missing signatures. During a concurrent interview and record review on 8/30/2023 at 3:10 p.m. with the DON of Patient 10s EMR medical record form titled ";POC/IDG Review" dated 7/6/2023, indicated MD signature, RN signature, and Chaplain signatures were left blank. It also indicated there was no input/discussion from spiritual and physician. DON confirmed the missed discipline discussions and the members missing signatures. A review of Patient 12 medical record form titled ";Patient Information" indicated a start of care date of 2/17/2023 with diagnoses including cerebrovascular disease (stroke). It also indicated MD1 was listed under ";referring/attending..." A review of Patient 12 medical record form titled ";Current Treatment/Medication/DME List" indicated ";IDT: to review patient status every 14 days and as needed to evaluate changes in patients condition." During a concurrent interview and record review on 8/30/2023 at 2:57 p.m. with the DON of Patient 12 s EMR medical record form titled ";POC/IDG Review – (As of 2/17/2023, Cert#1)" dated 2/17/2023, indicated ";RN signature and Chaplain signature" were left blank. DON stated that if the form is not signed by the indicated member, that that member was not present at the meeting. During a concurrent interview and record review on 8/30/2023 a t 3:11 p.m. with the DON of Patient 12 s EMR medical record form titled ";POC/IDG Review" dated 5/11/2023, indicated there was no input/discussion from spiritual, psychosocial, and physician. It also indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. DON confirmed the missed discipline discussions and the members missing signatures. During a concurrent interview and record review on 8/30/2023 at 3:11 p.m. with the DON of Patient 12 s EMR medical record form titled ";POC/IDG Review" dated 5/25/2023, indicated there was no input/discussion from psychosocial. It also indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. DON confirmed the missed discipline discussions and the members missing signatures. During a concurrent interview and record review on 8/30/2023 at 3:12 p.m. with the DON of Patient 12 s EMR medical record form titled ";POC/IDG Review" dated 6/8/2023, indicated MD signature, RN signature, and Chaplain signatures were left blank. DON confirmed the members missing signatures. During a concurrent interview and record review on 8/30/2023 at 3;12 p.m. with the DON of Patient 12 's EMR medical record form titled ";POC/IDG Review" dated 6/22/2023, indicated there was no input/discussion from spiritual. It also indicated MD signature, RN signature, and Chaplain signatures were left blank. DON confirmed the missed discipline discussions and the members missing signatures. During a concurrent interview and record review on 8/30/2023 at 3:13 p.m. with the DON of Patient 12's EMR medical record form titled ";POC/IDG Review" dated 7/6/2023, indicated there was no input/discussion from spiritual, nursing, and physician. It also indicated MD signature, RN signature, and Chaplain signatures were left blank. DON confirmed the missed discipline discussions and the members missing signatures. A review of Patient 13 medical record form titled ";Patient Information" indicated a start of care date of 2/24/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with unsp angina pectoris (decrease blood flow to the heart). A review of Patient 13 medical record form titled ";Current Treatment/Medication/DME List" indicated ";IDT: to review patient status every 14 days and as needed to evaluate changes in patients condition." During a concurrent interview and record review on 8/30/2023 at 2:59 p.m. with the DON of Patient 13s EMR medical record form titled ";POC/IDG Review – (As of 2/24/2023, Cert#1)" dated 2/24/2023, indicated ";RN signature and Chaplain signature" were left blank. DON stated that there were no signatures in those sections and was unsure if either of them attended the IDG meeting. During a concurrent interview and record review on 8/30/2023 at 3:13 p.m. with the DON of Patient 13s EMR medical record form titled ";POC/IDG Review" dated 6/22/2023, indicated MD signature, RN signature, and Chaplain signatures were left blank. DON confirmed the members missing signatures. During a concurrent interview and record review on 8/30/2023 at 3: 14 p.m., with the DON of Patient 13sEMR medical record form titled ";POC/IDG Review" dated 7/6/2023, indicated there was no input/discussion from spiritual and physician. It also indicated MD signature, RN signature, and Chaplain signatures were left blank. DON confirmed the missed discipline discussions and the members missing signatures. A review of Patient 14s medical record form titled ";Patient Information" indicated a start of care date of 2/21/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with angina pectoris (decrease blood flow to the heart). During a concurrent interview and record review on 8/30/2023 at 3 p.m. with the DON of Patient 14s EMR medical record form titled ";POC/IDG Review – (As of 2/21/2023, Cert#1)" dated 2/21/2023, indicated ";RN signature and Chaplain signature" were left blank. DON stated that she is not aware if the patient received the services in the plan of care. DON stated that the RN and Chaplain did not attend the IDG meeting. During a concurrent interview and record review on 8/30/2023 at 3:14 p.m. with the DON of Patient 14s EMR medical record form titled ";POC/IDG Review" dated 7/6/2023, indicated there was no input/discussion from spiritual and physician. It also indicated MD signature, RN signature, and Chaplain signatures were left blank. DON confirmed the missed discipline discussions and the members missing signatures. During a concurrent interview and record review on 8/30/2023 at 2:50 p.m. with the DON of Patient 14s EMR medical record form titled ";History of Nursing Assessment", DON stated there was one recertification comprehensive nursing assessment documented for P14, on 5/15/2023. DON stated that it was overdue and that she does not know who was supposed to complete it. DON stated that without it P14 could have missed care and needed his POC updated. During an interview on 8/28/2023 at 3 p.m., with the DON, the DON stated that the IDG meetings are completed amongst the hospice team. The team, which consist of the DON, MD, MSW, and Chaplain, go over the patients condition to determine if the meet hospice criteria. DON stated that all the members sign in on their EMR system and that their signature validates their attendance. DON also stated that prior to the start of a patients recertification period, the IDG get together and patients decline is discussed and that the MD will make the decision whether to recertify the patient or not. During an interview on 8/30/2023 at 3:15 p.m., with the DON, stated that the IDG meetings are comprehensive, and require all members to attend to assess the patients status and to determine if the patient still meets hospice criteria. DON stated that if the meetings are not held it could cause the patient to have missed services or not get the services that is on their plan of care. DON stated that their last IDG meeting was on 7/16/2023 because MD1 went on vacation, and they have not caught up. A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" undated, indicated ";A plan of care update will be completed for each patient and family/caregiver no less frequently than every 15 days utilizing the ongoing comprehensive assessment." A record review of the HAs policy and procedure titled, ";Comprehensive Assessment" undated, indicated ";The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days." A record review of the HAs policy and procedure titled, ";Ongoing Comprehensive Assessment" undated, indicated ";During each home visit, the Case Manager or the other discipline will evaluate the patient according to the problems identified... The scope and intensity of ongoing hospice patient assessment will be determined by the patients prognosis, diagnosis, condition...Based on the assessments, the plan of care – including problems, needs, goals, and outcomes – will be reviewed and updated by the interdisciplinary group members responsible for the care." A record review of the HAs policy and procedure titled, ";The Plan of Care" undated, indicated ";The written plan of care will contain, but will not be limited to, the following: frequency of services... interdisciplinary group assessment of needs..." A record review of the HAs policy and procedure titled, ";Clinical Data Collection Review" undated, indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services." A record review of the HAs policy and procedure titled, ";Admission Criteria and Process" undated, indicated ";The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determinations (LCDs). Eligibility criteria will be continually reviewed by the interdisciplinary team to ensure appropriateness of hospice care." A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" undated, indicated ";The hospice interdisciplinary team/group members will include, at a minimum: Physician, Registered Nurse, Social Worker, Pastoral... The interdisciplinary group will: participate in the periodic review and updating of the plan of care...".

Based on interview and record review, the Hospice Agency (HA) failed to meet the Condition of Participation for Interdisciplinary Group, Care Planning, and Coordination of Services as follows: --- 1. The HA failed to designate a registered nurse to coordinate and attend Interdisciplinary Group meetings (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide individualized care and support to patients and families) for ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14). (Refer to L540). 2. The HA filed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) developed and individualized plan of care for one of fourteen sample patients (Patient 9). (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) failed to designate a Registered Nurse (RN) to coordinate and attend interdisciplinary group meetings (IDG – meeting where the RN, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide individualized care and support to patients and families) for ten of fourteen sample patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5,Patient 8, Patient 9, Patient 10, Patient 12, Patient 13, and Patient 14). This deficient practice has the potential for the patients' progress or decline will not be identified by the IDG, interventions will not be implemented, and patient care goals will not be achieved. --- Findings: A record review of Patient 1's ";Personal Information" indicated a start of care on 7/5/23, with a diagnosis of chronic obstructive pulmonary disease (a lung condition). During an interview on 8/30/23, at 12:11 p.m., Registered Nurse 1 (RN 1) stated she did not do any of the initial comprehensive assessments for the HA. RN 1 stated she was not employed at the HA, has not signed any employment documents, and was shocked the HA was using her name in patients documents. RN 1 stated she did not know who P1 was. During an interview on 8/30/23, at 2:08 p.m., the DON stated she did not know RN 1 was not employed at the HA. During an interview on 8/30/23 at 3:23 p.m., the DON stated she did not attend any IDG meetings because she thought the visiting nurse was attending. The DON stated a registered nurse should attend the meeting to report the comprehensive assessment. The DON stated the Intake Coordinator (IC), who is not a registered nurse, was coordinating the IDG meetings. During a concurrent interview and record review on 8/30/23, at 3:30 p.m., the DON reviewed Patient 1'srecord titled, ";POC/IDG", dated 7/5/23. The record indicated Registered Nurse 1 (RN 1) documented the plan of care. The DON stated the registered nurse (RN), was not involved in the IDG meeting because the RN signature was not in the document. The signature indicated the RN provided input and participation in the discussion of the comprehensive assessment and care planning. The HA failed to ensure the RN coordinated and attended the IDG meetings. A record review of Patient 2s ";Personal Information" indicated a start of care on 6/15/23, with a diagnosis of chronic obstructive pulmonary disease (a lung condition). During a concurrent interview and record review on 8/30/23, at 3:33 p.m., the DON reviewed Patient 2s record titled, ";POC/IDG", dated 6/16/23. The record indicated RN 1 documented the plan of care. The DON stated the RN did not participate in the discussion of the comprehensive assessment. The DON stated she wouldnt know if the needs of Patient 2 were discussed because there was no documentation to show it. During a concurrent interview and record review on 8/30/23, at 3:34 p.m., the DON reviewed Patient 2s record titled, ";POC/IDG", dated 6/22/23. The record indicated RN 1 documented the plan of care. The DON stated there was no nursing discussion. The nursing discussion was important, so the IDG knows what is going on with the patient, their condition, what their needs are, and if the plan of care is being followed. The DON stated the RN did not participate in this IDG because there was no signature. During a concurrent interview and record review on 8/30/23, at 3:36 p.m., the DON reviewed Patient 2s record titled, ";POC/IDG", dated 7/6/23. The record indicated RN 1 documented the plan of care. The DON stated the RN did not participate in the IDG meeting because there was no signature. Continued review of the records indicated the IDG group did not meet anymore. The HA failed to ensure the RN coordinated and attended the IDG meetings. A record review of Patient 3s ";Personal Information" indicated a start of care on 3/8/23, with a diagnosis of heart disease. During a concurrent interview and record review on 8/30/23, at 3:37 p.m., the DON reviewed Patient 3s record titled, ";POC/IDG", dated 5/11/23. The record indicated the DON had documented the plan of care. The DON stated the RN did not participate in the IDG meeting because there was no signature. During a concurrent interview and record review on 8/30/23, at 3:38 p.m., the DON reviewed Patient 3s record titled, ";POC/IDG", dated 6/8/23. The record indicated the DON had documented the plan of care. The DON stated the RN did not participate in the IDG meeting because there was no signature. The DON stated the potential outcome of this was Patient 3s needs not being met. During a concurrent interview and record review on 8/30/23, at 3:39 p.m., the DON reviewed Patient 3srecord titled, ";POC/IDG", dated 6/22/23. The record indicated the DON documented the plan of care. The DON stated there was no nursing discussion. The nursing discussion was important, so the IDG knows what is going on with the patient, their condition, what their needs are, and if the plan of care is being followed. The DON stated the RN did not participate in this IDG because there was no signature. During a concurrent interview and record review on 8/30/23, at 3:40 p.m., the DON reviewed Patient 3srecord titled, ";POC/IDG", dated 7/6/23. The record indicated the DON documented the plan of care. The DON stated the RN did not participate in this IDG because there was no signature. Continued review of the records indicated the IDG group did not meet anymore. The HA failed to ensure the RN coordinated and attended the IDG meetings. A record review of Patient 4s ";Personal Information" indicated a start of care on 1/27/23, with a diagnosis of chronic obstructive pulmonary disease (a lung condition). During a concurrent interview and record review on 8/30/23, at 3:41 p.m., the DON reviewed Patient 4s record titled, ";POC/IDG", dated 5/11/23. The record indicated RN 1 documented the plan of care. The DON stated the RN did not participate in this IDG because there was no signature. The needs of the patients were not discussed because there was no signature to validate the discussion documented. During a concurrent interview and record review on 8/30/23, at 3:42 p.m., the DON reviewed Patient 4s record titled, ";POC/IDG", dated 5/25/23. The record indicated RN 1 documented the plan of care. The DON stated the RN did not participate in this IDG because there was no signature. The needs of the patients were not discussed because there was no signature to validate the discussion documented. During a concurrent interview and record review on 8/30/23, at 3:42 p.m., the DON reviewed Patient 4s record titled, ";POC/IDG", dated 6/8/23. The record indicated RN 1 documented the plan of care. The DON stated the RN did not participate in this IDG because there was no signature. The needs of the patients were not discussed because there was no signature to validate the discussion documented. During a concurrent interview and record review on 8/30/23, at 3:43 p.m., the DON reviewed Patient 4s record titled, ";POC/IDG", dated 6/22/23. The record indicated RN 1 documented the plan of care. The DON stated the RN did not participate in this IDG because there was no signature. The needs of the patients were not discussed because there was no signature to validate the discussion documented. Continued review of the records indicated the IDG group did not meet anymore. The HA failed to ensure the RN coordinated and attended the IDG meetings. A record review of Patient 5s ";Personal Information" indicated a start of care on 3/20/23, with a diagnosis of hypertensive (high blood pressure) heart disease with heart failure. During a concurrent interview and record review on 8/30/23, at 3:44 p.m., the DON reviewed Patient 5s record titled ";POC/IDG" dated 5/11/23. The DON stated the RN signature was missing. During a concurrent interview and record review on 8/30/23, at 3:44 p.m., the DON reviewed Patient 5s record titled ";POC/IDG" dated 5/25/23. The DON stated the RN signature was missing. During a concurrent interview and record review on 8/30/23, at 3:45 p.m., the DON reviewed Patient 5s record titled ";POC/IDG" dated 6/8/23. The DON stated the RN signature was missing. During a concurrent interview and record review on 8/30/23, at 3:46 p.m., the DON reviewed Patient 5s record titled ";POC/IDG" dated 7/6/23. The DON stated there was no nursing discussion documented, and P5s needs were not identified. The DON stated the RN signature was missing. Continued review of the records indicated the IDG group did not meet anymore. The HA failed to ensure the RN coordinated and attended the IDG meetings. A review of Patient 8s medical record form titled ";Patient Information" indicated a start of care date of 12/8/2022 with diagnoses including chronic obstructive pulmonary disease (COPD – difficulty breathing). During a concurrent interview and record review on 8/30/2023 at 2:50 p.m. with the Director of Nurses (DON) of Patient 8s EMR medical record form titled ";POC/IDG Review – (As of 12/8/2022, Cert#1)" dated 12/8/2022, indicated ";RN signature" was left blank. DON stated that the signatures validate the members attendance. A review of Patient 9 medical record form titled ";Patient Information" indicated a start of care date of 5/15/2023 with diagnoses including Alzheimers Disease (degenerative brain tissue – memory loss). It also indicated Nurse Practitioner 1 (NP1) was the ";referring/attending/patient choice". During a concurrent interview and record review on 8/30/2023 at 2;53 p.m. with the DON of Patient 9s EMR medical record form titled ";POC/IDG Review – (As of 5/15/2023, Cert#1)" dated 5/15/2023, indicated ";RN signature" was left blank. DON stated that she is not aware of the patient received the services in the plan of care. DON stated that the member signatures indicated that they were present and that they agreed with the patients plan of care. A review of Patient 10 medical record form titled ";Patient Information" indicated a start of care date of 1/27/2023 with diagnoses including end stage heart failure (progressive heart failure). It also indicated MD3 was the referring MD. During a concurrent interview and record review on 8/30/2023 at 2:56 p.m. with the DON of Patient 10s EMR medical record form titled ";POC/IDG Review – (As of 1/27/2023, Cert#1)" dated 1/27/2023, indicated ";RN signature" was left blank. DON stated that she is not aware if the patient received the services in the plan of care. DON stated that the members were supposed to sign the form to validate their attendance and agree with the plan of care for the patient. A review of Patient 12 medical record form titled ";Patient Information" indicated a start of care date of 2/17/2023 with diagnoses including cerebrovascular disease (stroke). It also indicated MD1 was listed under ";referring/attending..." During a concurrent interview and record review on 8/30/2023 at 2:57 p.m., with the DON of P12s EMR medical record form titled ";POC/IDG Review – (As of 2/17/2023, Cert#1)" dated 2/17/2023, indicated ";RN signature" was left blank. DON stated that if the form was not signed by the indicated member, then that member was not present at the meeting. A review of Patient 13 medical record form titled ";Patient Information" indicated a start of care date of 2/24/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with angina pectoris (decrease blood flow to the heart). During a concurrent interview and record review on 8/30/2023 at 2:59 p.m., with the DON of P13s EMR medical record form titled ";POC/IDG Review – (As of 2/24/2023, Cert#1)" dated 2/24/2023, indicated ";RN signature" was left blank. DON stated that there were no signatures in those sections and was unsure if either of them attended the IDG meeting. A review of Patient14 medical record form titled ";Patient Information" indicated a start of care date of 2/21/2023 with diagnoses including atherosclerotic heart disease of native coronary artery with angina pectoris (decrease blood flow to the heart). During a concurrent interview and record review on 8/30/2023 at 3 p.m., with the DON of Patient 13s EMR medical record form titled ";POC/IDG Review – (As of 2/21/2023, Cert#1)" dated 2/21/2023, indicated ";RN signature" was left blank. DON stated that she is not aware if the patient received the services in the plan of care. DON stated that the RN did not attend the IDG meeting. During an interview on 8/28/2023, at 3 p.m., with the Director of Nurses (DON), DON stated that the meetings are held by the members, MD, MSW, RN, and Chaplain to go over the patients condition and to determine if they meet criteria for hospice. DON stated that all members sign through their EMR, and that their signatures indicate that they were present in the meeting. DON stated that their signatures validate their attendance. DON stated that each discipline writes their own narrative. During an interview on 8/30/2023 at 3:27 p.m. with the DON, the DON stated that she does not attend the IDG meetings. DON stated that she assumed the visiting nurses attended. During an interview on 8/30/2023 at 3:30 p.m. with the Administrator (ADM), the ADM stated that he has no clinical experience and does not know who attends or what is discussed at the IDG meetings. A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" undated, indicated ";The hospice interdisciplinary team/group members will include, at a minimum... Registered Nurse...". It also indicated A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" undated, indicated ";The hospice interdisciplinary team/group members will include, at a minimum: Physician, Registered Nurse, Social Worker, Pastoral..."

Based on interview, and record review, the hospice agency (HA) failed to ensure the interdisciplinary group, in consultation with the patients attending physician prepare a written plan of care (POC – individualized patient plan of care describing the type of care and services needed) for one of fourteen sample selected patients (Patient 9). This deficient practice resulted in the patients not receiving the care /services identified in the POC affecting their quality of care and health status. --- Findings: A review of Patient 9s medical record form titled ";Patient Information" indicated a start of care date of 5/15/2023 with diagnoses including Alzheimers Disease (degenerative brain tissue – memory loss). It also indicated Nurse Practitioner 1 (NP1) was the ";referring/attending/patient choice". A review of Patient 9s medical form titled, ";Comprehensive Nursing Assessment" dated 5/15/2023, indicated sections ";Wt (lbs); MAC (cm)" and ";Nature & Condition of Terminal Illness/LCD eligibility" were left blank. It also indicated NP1 signed the form. A review of Patient 9 medical record form titled ";Physicians Certification for Hospice Benefit – Statement for first 90-day period" dated from 5/15/2023 to 8/12/2023, indicated NP1s name was documented on ";Physician Name". It also indicated Intake Coordinator (IC) signed under ";Signature on file/verified by (IC)." Lastly, form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice..." A record review of Patient 9 Electronic Medical Record (EMR) form titled ";POC/IDG Review" dated 5/15/2023, indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. It also indicated ";Alert! Complete level of care (LOC) or frequency of visits or staff assigned information prior to signing". A review of Patient 9 medical record form titled ";POC/IDG Review" dated 5/25/2023, indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. It also indicated sections ";Frequency of visits and plan of care (problem/interventions/goals/status) – (total 0 issues)" were left blank. A review of Patient 9 medical record form titled ";POC/IDG Review" dated 6/8/2023, indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. It also indicated sections ";Frequency of visits and plan of care (problem/interventions/goals/status) – (total 0 issues)" were left blank. A review of Patient 9 medical record form titled ";POC/IDG Review" dated 6/22/2023, indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. It also indicated sections ";Frequency of visits and plan of care (problem/interventions/goals/status) – (total 0 issues)" were left blank. A review of Patient 9 medical record form titled ";POC/IDG Review" dated 7/6/2023, indicated MD signature, MSW signature, RN signature, and Chaplain signatures were left blank. It also indicated sections ";Frequency of visits and plan of care (problem/interventions/goals/status) – (total 0 issues)" were left blank. A review of Patient 9s medical record form titled ";POC Summary" indicated ";Frequency of visit" was left blank. It also indicated the Medical Doctor 1s (MD1) name was documented on form, but form was not signed. During a concurrent interview and record review on 8/30/2023 at 3:04 p.m. with the DON of P9s ";IDG/POC Review" dated 5/15/2023, 5/25/2023, 6/8/2023, 6/22/2023, and 7/6/2023, DON stated that she does not why they were not completed. DON stated that ";its an issue" because staff, patients, and their families will not know what their plan of care is. DON stated that missed treatments and care are a possibility. DON stated that by looking at the records, she does not know what P9s issues are. During an interview on 8/28/2023, at 3 p.m., with the Director of Nurses (DON), the DON stated that the POC is composed by the contributions of the IDG meetings. DON stated that the POC addresses what care needs to be provided to patients. A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" undated, indicated ";Each patients plan of care will be updated utilizing the results from the ongoing comprehensive assessment no less frequently than every 15 days or more frequently if the patients condition requires." A record review of the HAs policy and procedure titled, ";Initial Assessment" undated, indicated ";Based on the initial assessments, the plan of care will be initiated on the day of admission." A record review of the HAs policy and procedure titled, ";The Plan of Care" undated, indicated ";A written individualized patient and family/caregiver plan of care will be established and maintained for each individual admitted to the hospice program. The Case Manager (or admitting registered nurse) will complete the initial assessment and will initiate the development of the plan of care...The plan of care will be reviewed prior to care being delivered." A record review of the HAs policy and procedure titled, ";Physician Services – Medical Director" undated, indicated ";The duties and responsibilities of the Medical Director will include, but not be limited to, the following: establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care..." A record review of the HAs policy and procedure titled, ";Clinical Data Collection Review" undated, indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services." A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" undated, indicated ";The hospice interdisciplinary team/group members will include, at a minimum: Physician, Registered Nurse, Social Worker, Pastoral... The interdisciplinary group will: participate in the establishment of the plan of care..."

Based on interview and record review the Hospice Agency (HA) failed to ensure the Administrator (ADM) is qualified to assume full authority and responsibility for day-to-day operations of the HA. This failure resulted in patients admitted for hospice care services are not being certified by a physician for hospice care and/or patients not meeting hospice criteria. --- Findings: A record review of the HAs ";Organizational Chart" undated, indicated the Administrator (ADM) name was under ";Administrator". It also indicated the DON was listed under ";Director of Nursing". During an interview on 8/30/2023, at 3:35 p.m., with the ADM, stated that he has no health care experience and does not know what is going on. ADM stated that he was a businessman. ADM stated that he hired the Director of Nurses (DON) and the Intake Coordinator (IC) because he thought they knew what they were doing. ADM stated that he does not know how to use the HAs Electronic Medical Record (EMR), and does not have a logging to it because he does not use it or logs in. ADM stated that his role as the ADM is to make sure the patients are being visited and the employees are getting paid. A record review of the HAs form titled ";Licensure & Certificate Application (LCA)" dated 8/4/2023, indicated the Director of Nurses (DON) was listed under section ";Name of Person to be in charge of facility, agency, or clinic (DON) – Title DPCS (Director of Patient Care Services / Administrator". During a concurrent interview and record review on 8/30/2023, at 4:10 p.m., with the DON of the HAs LCA dated 8/4/2023, the DON stated that she was not the ADM of the HA. The DON stated I was hired on 3/1/2023 as the DON by the ADM. During a concurrent interview and record review on 8/30/2023 at 4:14 p.m. with the ADM of the HAs LCA dated 8/4/2023, indicated the HA requested a change of address and ADM. The ADM stated that he was the current ADM of the HA. The ADM stated that their ";consultant" filled the form out. During a concurrent interview and record review on 8/30/2023 at 4:14 p.m. with the DON of her employee file, the DON stated that she never filled out an HA application for employment and that the signatures on the papers inside her file are not hers. During an interview on 8/30/2023 at 4:16 p.m. with the ADM, the ADM stated that the DON emailed him her credentials sometime on 11/2022. ADM stated that he did not go over the employee file papers with the DON, ";I dont know who did". ADM stated that he was not involved with the ";computer" and does not know what happened after that. An interview on 8/30/2023 at 4:20 p.m. with the DON, the DON stated that she emailed her credentials to the ADM on 2/1/2023. DON stated that she has never seen the papers inside her employee file. A review facilitys form titled ";Job Title/Position: Executive Director/Administrator" undated, indicated ";The Executive Director/Administrator is... responsible for the employment of qualified hospice personnel; is responsible for the provision of hospice services, directly and the delegation to and coordination of hospice personnel evaluations; is responsible for establishing standards of care to comply with federal and state regulations and guidelines."

Based on observation, interview, and record review the Hospice Agency (HA) failed to notify the Department of their change of location. This failure resulted in the Department, the hospice patients, and their caregivers/families not being aware of the current location of the hospice agency and making it difficult to locate/contact. --- Findings: During an unannounced visit to HA address on file indicated HA was not operating at that address. During a telephone interview on 8/28/2023, at 11:50 a.m., with the Administrator (ADM), the ADM stated that they were no longer at address on file and that they had move to new location about 6-7 months ago. During an unannounced visit to the current HA address, the Intake Coordinator (IC) was on site. During an interview on 8/28/2023, at 12:40 p.m., with IC, stated that they have been at current location since she began her employment in December 2022. A record review of facilitys public brochure indicated HAs new address was listed as their business address. A record review of the HAs form titled ";Licensure & Certificate Application (LCA)" dated 8/4/2023, indicated the HA was applying for a change of address location on 8/4/2023. A record review of HAs form with the HAs name written on the top of the form dated 8/4/2023, indicated the HAs Chief Financial Officer (CFO) was informing the Department (CAB) of an address change effective 1/1/2023. It also indicated the CFO signed the form. A record review of the HAs policy and procedure titled, ";Reporting of Changes" undated, indicated ";It is the policy of the (HA) to notify the California Department of Public Health of any changes in the hospice agencys... location...Administrator... The owner or designee will, within 10 days, notify the Department in writing of the following: change of location and/or address of (HA). Change of the Administrator..."

Based on observation, interview, and record review, the hospice agency (agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Condition of Participation (conditions for coverage that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs) for Medical Director was met as evidenced by: --- 1. The hospice agency failed to ensure the Medical Director or a physician designee (who is a hospice employee or under the contract with the hospice) reviewed the patients' clinical information to determine hospice (health care that focuses on the palliation [easing the severity of a pain or a disease without removing the cause] of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care criteria and provide an initial written certification to indicate the patients had six months or less to live if the illness runs its normal course for seven of 14 sampled patients (Patients 1, 2, 3, 9, 10, 11 and 12). (Refer to L 667). 2. The hospice agency failed to ensure the Medical Director or a physician designee conducted a review and verified the clinical information for eight of 14 sampled patients (Patients 3, 4, 5, 8, 10, 12, 13, and 14) to determine the patients' needs of recertification (to certify again) of terminal illness (an illness or condition which cannot be cured and is likely to lead to someone's death) for continued hospice care and services. (Refer to L 668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated (State law) 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.

Based on observation, interview, and record review, the hospice agency (agency providing care to terminally ill patients who have six months or less to live) failed to ensure the Medical Director or a physician designee (who is a hospice employee or under the contract with the hospice) reviewed the patients' clinical information to determine hospice (health care that focuses on the palliation [easing the severity of a pain or a disease without removing the cause] of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care criteria and provide an initial written certification to indicate the patients had six months or less to live if the illness runs its normal course for seven of 14 sampled patients (Patients 1, 2, 3, 9, 10, 11, and 12). This deficient practice resulted in the hospice Medical Director and/or the physician designee to certify Patients 1, 2, 3, 9, 10, 11, and 12 for hospice care without documentation of clinical evidence to support Patients 1, 2, 3, 9, 10, 11, and 12's terminal illnesses diagnoses which could affect the care provided to Patients 1, 2, 3, 9, 10, 11, and 12. --- Findings: 1. A record review of Patient 1 s ";Personal Information," indicated a start of care on 7/5/2023, with a diagnosis of chronic obstructive pulmonary disease (COPD, a disease that damages the lungs in ways that make it hard to breathe). During an interview on 8/30/2023 at 10:22 a.m., the Medical Director 1 (MD 1) stated a licensed nurse (in general) would see the patients (in general) and document information in the patients (in general) records. MD 1 stated he did not see patients (in general) himself because he had so much work and used a nurse practitioner to see the patients. MD 1 stated he reviewed nursing notes to determine if a Patient (in general) was eligible for hospice care. During a concurrent interview and record review on 8/30/2023, at 10:31 a.m., MD 1 reviewed Patient 1s record titled, ";Physicians Certification for Hospice Benefit," for certification period 7/5/2023 to 10/2/2023. MD 1 stated he composed the physician narrative based on the nursing assessment. MD 1 stated he used a history and physical (H&P- a medical document describing past and current illnesses with plans of treatment) to assist him in the medical assessment for hospice criteria for Patient 1. MD 1 stated he usually wrote an H&P and included it in the document. MD 1 stated he was not sure why the H&P document was not in Patient 1s record. Further review of the record indicated, ";By signing I attest that I composed the above narrative based on my review of record and/or examination of Patient." During a concurrent interview and record review on 8/30/2023, at 12:11 p.m., the Director of Nursing (DON), reviewed Patient 1s record titled, ";Comprehensive Nursing Assessment," dated 7/5/2023. The DON stated the record indicated Patient 1 was eligible for hospice services because Patient 1 had a poor response to bronchodilators (medications used to open the airways in the lungs), he had respiratory failure (is a serious condition that makes it difficult to breathe on your own) and had unintentional progressive weight loss over the last six months. The DON stated the record indicated Registered Nurse 1 (RN 1) performed the initial 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) on 7/5/2023. When asked where the information was obtained to determine the criteria for hospice care, the DON stated, ";I am guessing from the nurses assessment." During an interview on 8/30/2023, at 12:11 p.m., RN 1 stated she did not do any of the initial comprehensive assessments for the hospice agency. RN 1 stated she was not employed at the hospice agency and did not sign any employment documents. RN 1 stated she was ";shocked," the hospice agency used her name in Patient 1 documents. RN 1 stated she did not know who Patient 1 was. During an interview on 8/30/2023, at 2:08 p.m., the DON stated she did not know if Patient 1s initial comprehensive assessment was accurate because she did not know RN 1 was not employed at the hospice agency. The DON stated she did not know who saw Patient 1 for the initial comprehensive assessment. 2. A record review of Patient 2s ";Personal Information" indicated a start of care on 6/15/2023, with a diagnosis of COPD. During a concurrent interview and record review on 8/30/2023, at 10:40 a.m., MD 1 reviewed Patient 2s record titled, ";Physicians Certification for Hospice Benefit," for certification period 6/16/2023 to 9/13/2023. Concurrently, MD 1 also reviewed Patient 1s record titled, ";Physicians Certification for Hospice Benefit," for certification period from 7/5/2023 to 10/2/2023. MD 1 stated Patient 2 and Patient 1s physician narrative was identical (same). MD 1 stated, ";I should have documented his additional findings, what his worsening is, I should have added those details, with my physicians findings, I didnt, my bad. I didnt add the specific findings," for Patient 2. MD 1 stated he did not see any additional medical documents uploaded in Patient 2s records and he did not remember if he had any records to look at when doing his medical assessment of Patient 2. 3. A record review of Patient 3s ";Personal Information," indicated a start of care on 3/8/2023, with a diagnosis of heart disease. During a concurrent interview and record review on 8/30/2023, at 1:15 p.m., the Intake Coordinator (IC) reviewed Patient 3s record titled, ";Physicians Certification for Hospice Benefit," for certification period 3/8/2023 to 6/5/2023. The record indicated, ";Medical Director Attestation/Certification: I attest/confirm that I composed this narrative based on my review of Patients medical record, team assessment and/or examination of the Patient. Signature on File/Verified by the IC." The IC stated Medical Doctor 2 (MD 2) told her to sign the document. The IC stated MD 2 had written the physician narrative. During a concurrent interview and record review on 8/30/2023, at 1:18 p.m., the IC reviewed Patient 3s record titled ";Audit Log", dated 3/8/2023 to 8/30/2023. The record indicated the IC documented on the physician narrative for certification period 3/8/2023, on 6/5/2023. The IC stated she was not aware of who entered the information because it was not her. 4. A review of Patient 9s medical record form titled ";Patient Information," indicated a start of care date of 5/15/2023 with diagnoses including Alzheimers Disease (memory loss) and also indicated Nurse Practitioner 1 (NP 1) was the ";referring/attending/Patient choice." A review of Patient 9s medical form titled, ";Comprehensive Nursing Assessment," dated 5/15/2023, indicated sections ";Weight (pounds); MAC (cm)" and ";Nature & Condition of Terminal Illness/LCD eligibility" were left blank. It also indicated Patient 1 signed the form. A review of Patient 9s medical record form titled ";Physicians Certification for Hospice Benefit – Statement for first 90-day period," dated from 5/15/2023 to 8/12/2023, indicated NP1s name was documented on ";Physician Name." The form also indicated the IC signed under ";Signature on file/verified by (IC)." Lastly, form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice..." A review of Patient 9s medical record form titled ";Physicians Certification for Hospice Benefit" dated from 5/15/2023 to 8/12/2023, indicated MD2s name was documented on ";Physician Name." The form also indicated IC signed under ";Signature on file/verified by (IC)." Lastly, form indicated ";I attest/confirm that I composed this narrative based on my review of Patients medical record, team assessment and/or examination of the Patient." On 8/29/2023 at 1:28 p.m., the surveyor called NP1 to the number listed on the hospice agencys employee list, with no answer. Message with call back number left. During an interview on 8/30/2023 at 10:11 a.m., with the DON, the DON stated NP 1 was not available all day due to her work schedule. On 8/30/2023 at 12:55 p.m., the surveyor called NP1 to the number listed on the hospice agencys employee list, with no answer. Message with call back number left. 5. A review of Patient 10s medical record form titled ";Patient Information," indicated a start of care date of 1/27/2023 with diagnoses including end stage heart failure (progressive heart failure). It also indicated MD3 referred Patient 10 to the hospice agency. A review of Patient 10s medical record form titled ";Physician Certification for Hospice Benefit – Statement for first 90-day period," dated from 1/27/2023 to 4/26/2023, indicated MD3s name was documented on the ";Physician Name." The form indicated the DON signed under ";Signature on file/verified by (DON)." Lastly, the form indicated ";It is my clinical judgement that this Patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice..." During an observation, interview, and a joint home visit on 8/29/2023 at 10:40 a.m., with Licensed Vocational Nurse 1 (LVN1) to Patient 10s home, LVN1 stated sometimes he (LVN 1) was unable to see Patient 10 because Patient 10 was not at home. LVN1 stated Patient 10 attended an adult day care center. Patient 10 was awake and alert and walked using a walker (is a type of mobility aid that offers stability and support while walking). Patient 10 stated he had not used the oxygen provided by the hospice agency because he did not get short of breath. Patient 10 stated he attended an adult day care center where he conducted ";mind and physical exercise." Patient 10 stated he performed all his activities of daily living (ADL – activities of daily living, essential and routine tasks), but he did not shower by himself. Patient 10 stated he had a primary physician (MD3) since 2007 but had not seen her because he had been in either hospice or home health since then. Patient 10 stated he had never been told he had six months or less to live. Patient 10 stated a marketer (MK) told him there were two types of hospice services, one for those who are bedridden and those who could attend adult day care centers. During a phone interview on 8/29/2023 at 12:51 p.m. with MD3s nurse (MDN), MDN stated they received a call from Patient 10s son on December 2022, stating Patient 10 received hospice services. MDN stated Patient 10 was seen by MD3 from 2010 – 2022. MDN stated MD3 did not refer Patient 10 to the hospice agency. 6. A review of Patient 11s medical record form titled ";Patient Information," indicated a start of care date of 7/12/2023 and an end of care date of 7/24/2023 with diagnosis of Alzheimers Disease. A review of Patient 11s medical record form titled ";Physician Certification for Hospice Benefit – Statement for first 90-day period," dated from 7/12/2023 to 10/9/2023, indicated MD 4s name was documented on ";Physician Name," and the form was not signed. During a concurrent interview and record review on 8/30/2023 at 11:07 a.m., with MD1 of Patient 11s form titled ";Physician Certification for Hospice Benefits – Certification #1" dated from 7/12/2023 to 10/9/2023, MD1 stated his narrative under section ";Certifying Physician Summary" documented on the form was based on the comprehensive nursing assessment completed by RN1. A review of Patient 11s medical record form titled ";Comprehensive Nursing Assessment" dated 7/12/2023, indicated the assessment was signed by RN1. A record review of the hospice agencys ";Organizational Chart" undated, indicated RN1 was listed under ";DPCS (Director of Patient Care Services) Designee." During an interview on 8/28/2023 at 3p.m., with the DON, the DON stated RN1 was the DON designee during the entrance conference. During an interview on 8/30/2023, at 12:11 p.m., RN 1 stated she did not do any of the initial comprehensive assessments for the hospice agency. RN 1 stated she was not employed at the hospice agency and did not sign any employment documents, and stated she was ";shocked," the hospice agency used her name in Patient 11s documents. During an interview on 8/30/2023, at 2:08 p.m., the DON stated she did not know RN 1 was not employed at the hospice agency. During an interview on 8/30/2023 at 3:35 p.m., with the Administrator (ADM), the ADM stated RN1 emailed him her nursing her credentials, but she never worked for the hospice agency. ADM stated RN1 never received a paycheck from the hospice agency. The ADM stated the IC was the only person who was able to provide EMR access to the HAs employees. ADM stated that he was not familiar with the electronic medical record (EMR) the hospice agency used. 7. A review of Patient 12s medical record form titled ";Patient Information" indicated a start of care date of 2/17/2023 with diagnosis of cerebrovascular disease (stroke is a loss of blood flow to part of the brain) and indicated MD1 was listed under ";referring/attending..." A review of Patient 12s medical record form titled ";LCD Hospice Eligibility Determination" dared 2/21/2023 and 7/20/2023. The record indicated ";Stroke and Coma – for A-Stroke 1 and 2 should be met." It also indicated, ";2. c. Current HX (history) of pulmonary aspiration not responding to speech language pathology intervention? (Sequential calorie counts documenting inadequate caloric/fluid intake): YES and d. Dysphagia severe enough to prevent Patient from continuing fluids/food necessary to sustain life and Patient does not receive artificial nutrition and hydration: YES." A review of Patient 12s medical record form titled ";Physician Certification for Hospice Benefit – Statement for first 90-day period," dated from 2/17/2023 to 5/17/2023, indicated MD2s signed the record. During an observation, interview, and a joint home visit on 8/29/2023 at 11:40 a.m., with LVN1 to Patient 12s home, Patient 12 was laying supine (face up) in a hospital bed, awake working on a crossword puzzle. Patient 12 could not move her left arm, Patient 12 signed consent for home visit with her right hand. LVN1 noted performing gastrostomy tube (GT – a soft tube inserted into the stomach by an opening in the abdominal wall, used to provide nutrition) care. Care Giver 1 (CG1) stated Patient 12 had a primary physician (MD5), the same physician since 2001, which she saw earlier this month. CG1 stated she assisted Patient 12 onto her wheelchair and they both took the public bus to see MD5. CG1 stated MD5 had not told them Patient 12 had six months or less to live. CG1 stated she was referred by a nurse (RN4) and was told hospice was for patients (in general) who are bedridden, unable to see primary physician by themselves, and hospice provided supplies. CG1 stated she switched Patient 12 from home health care to hospice because Patient 12 needed the hospital bed. CG1 stated the bed was a rental, and that Medicare covered it through the hospice agency. During a telephone interview on 8/29/2023 at 12:12 p.m., with Patient 12s primary physician (MD5), MD5 stated Patient 12 was his patient for many years and just saw her this month. MD5 stated Patient 12 was not a hospice candidate and should not be receiving hospice services. MD5 stated Patient 12 was not dying. During a concurrent interview and record review on 8/30/2023 at 11:08 a.m. with MD1 of Patient 12s EMR form titled ";Physician Certification for Hospice Benefits – Certification #2" dated from 5/18/2023 to 8/15/2023, MD1 stated Patient 12 was not his Patient. MD1 stated, ";Yes, my name is printed on the CTI [certification of terminal illness], but I am not involved with this Patient care. I did not give permission to anyone to use my name or sign for me. This is not my Patient." During an interview on 8/28/2023 at 3 p.m. with the DON, the DON stated in general, MD 1 based the CTI from the RNs assessment, their visits, and the patients medical record. DON stated the CTI should be completed 14 days before and within two days of the patients admission and before every recertification. DON stated that the MD signs the CTI to certify the patient met hospice criteria. During a telephone interview on 8/30/2023 at 10:22 a.m. with MD1, MD1 stated, in general, he used the nursing assessments notes to approve or disapprove the patients admission. MD1 stated he requested the patients H&P and their medication list. MD1 stated he usually conducted the face-to-face visit via telehealth, and he rarely saw the patients at their homes. MD1 stated he had a lot of work and that working at the hospice agency was a side job for him. MD1 stated he would go to the patients home if he was close by. MD1 stated the hospice agency had an NP (NP1) who would go to the patients homes for the recertifications. MD1 stated after NP 1 saw the patients, they would discuss the case and he then determined if the patient would continue with hospice services or not. MD1 stated there was an interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) meeting every two weeks where they would discuss the patients. MD1 stated he documented his narrative under section ";Certifying Physician Summary" in the patients CTI form. MD1 stated that his signature was electronic. MD1 stated he had not shared his EMR logging information with anyone. A record review of the hospice agencys policy and procedure titled, ";Comprehensive Assessment" undated, indicated ";The assessment should determine probable prognosis of six (6) months or less". A record review of the hospice agencys policy and procedure titled, ";Certification of Terminal Illness" undated, indicated ";When certifying the patient as terminally ill, the hospice medical director must considerate least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification." A record review of the hospice agencys policy and procedure titled, ";Physician Services – Medical Director" undated, indicated ";The duties and responsibilities of the Medical Director will include, but not be limited to, the following: Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness." A record review of the hospice agency's policy and procedure titled, ";Clinical Data Collection Review" undated, indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services." A record review of the hospice agency's policy and procedure titled, ";Admission Criteria and Process" undated, indicated ";The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determinations (LCDs). (HA) will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician. The patients physician must order and approve the provision of hospice care. The patient must desire hospice services and be aware of the diagnosis and prognosis, Eligibility criteria will be continually reviewed by the interdisciplinary team to ensure appropriateness of hospice care."

Based on observation, interview, and record review the hospice agency (agency providing care to terminally ill patients who has six months or less to live) failed to ensure the Medical Director or a physician designee conducted a review and verified the clinical information for eight of fourteen sampled patients (Patients 3, 4, 5, 8, 10, 12, 13, and 14) to determine the patients' needs of recertification (to certify again) of terminal illness (an illness or condition which cannot be cured and is likely to lead to someone's death) for continued hospice care and services. This deficient practice resulted for the Medical Director or physician designee not to review Patient 3, 4, 5, 8, 10, 12, 13, and 14's clinical information and had the potential for Patients 3, 4, 5, 8, 10, 12, 13, and 14 not to receive the necessary care and services. --- Findings: 1. A record review of Patient 3s ";Personal Information," indicated a start of care on 3/8/2023, with a diagnosis of heart disease (illness of the heart). During an interview on 8/28/2023, at 1:54 p.m., the case manager (CM) stated Patient 3s recertification nursing assessment for 6/6/2023 was not done. During a concurrent interview and record review on 8/30/2023, at 10:49 a.m., the Medical Director 1 (MD 1) reviewed Patient 3s record titled, ";Physicians Certification for Hospice Benefit," for certification period 6/6/2023 to 9/3/2023. MD 1 stated he determined Patient 3 was eligible to continue hospice care based on his review of the previous medical director (unidentified) notes and nursing notes. 2.A record review of Patient 4s ";Personal Information," indicated a start of care on 1/27/2023, with a diagnosis of chronic obstructive pulmonary disease (COPD, a disease that damages the lungs in ways that make it hard to breathe). During a concurrent interview and record review on 8/30/2023, at 10:49 a.m., MD 1 reviewed Patient 4s record titled, ";Physicians Certification for Hospice Benefit," for certification period 7/26/2023 to 9/23/2023. MD 1 stated the record indicated certification was based on a face-to-face encounter. MD 1 stated he did not remember if he saw Patient 4. MD 1 stated he did not see documented evidence in Patient 4s records that a face-to-face encounter was done by MD 1, a nurse practitioner, or a physicians assistant. MD 1 stated a face-to-face encounter was supposed to be done one month prior to recertification, on 6/26/2023. MD 1 stated he signed the document on 7/26/2203, the day Patient 4 was recertified, despite MD 1 not recalling when the face-to-face encounter was made. MD 1 recertified Patient 4 for hospice care without a face-to-face medical visit. A record review of Patient 4s record titled, ";Audit Log," dated 1/26/2023 to 8/20/2023, indicated MD 1 documented and signed the physician narrative for certification period 7/26/2023, on 8/24/2023. The log indicted the hospice agency continued to provide hospice services to Patient 4 without a doctors certification. 3.A record review of Patient 5s ";Personal Information," indicated a start of care on 3/20/23, with diagnoses of hypertensive (high blood pressure) heart disease with heart failure. During an observation of the home visit on 8/29/2023 at 9:31 a.m., Licensed Vocational Nurse 1 (LVN 1) performed a nursing visit. Patient 5 was sitting on a sit to stand walker (a type of mobility aid that offers stability and support while walking), propelling (driving) himself around the kitchen. Patient 5 was breathing normally without the use of supplemental oxygen. During an observation and an interview on 8/29/2023, at 9:40 a.m., Patient 5 stated to LVN 1 he used his walker to walk outside every day. During a concurrent observation and interview on 8/29/2023, at 9:45 a.m., a portable oxygen tank, oxygen concentrator (a medical device that gives a person extra oxygen), and an unopened packet with oxygen tubing was observed in Patient 5s living room. Patient 5 stated he had never used the oxygen because he did not need it. During an interview on 8/29/2023, at 9:50 a.m., Patient 5 stated he had a primary care doctor (MD 6). Patient 5 stated the doctors (in general) did not tell him he had six months or less to live. During an interview on 8/29/2023, at 2:05 p.m., MD 6 stated he saw Patient 5 on 7/11/2023. MD 6 stated Patient 5 was not terminal and Patient 5 did not have a medical condition resulting in a life expectancy of six months or less to live. MD 6 stated he referred Patient 5 to a hematologist (doctor who specializes in the blood) and nephrology (doctor who specializes in the kidneys) due to his medical condition. During a concurrent interview and record review on 8/30/2023, at 10:57 a.m., MD 1 reviewed Patient 5s record titled ";Physicians Certification for Hospice Benefit," for certification 6/18/2023 to 9/15/2023. MD1 stated the record indicated Patient 5 had symptoms of recurrent angina (recurring chest pain) at rest along with discomfort with any activity. MD 1 stated he recertified Patient 5 for hospice care based on the review of the nursing notes, previous primary care doctor, and everything in the chart. MD 1 stated there were scanned records from Patient 5s referring doctor and those records did not have any documentation about Patient 5 being terminal or having six months or less to live. 4.A review of Patient 8s medical record form titled ";Patient Information," indicated a start of care date of 12/8/2022 with diagnosis of COPD. A review of Patient 8s medical record form titled ";Physicians Certification for Hospice Benefit," dated 8/5/2023 to 10/3/2023, indicated the RN (Registered Nurse) prognosis summary, and the Physician narrative were left blank. It also indicated the Medical Directors (MD) signature was left blank. During a concurrent interview and record review on 8/30/2023 at 11 a.m., with MD1 of Patient 8s Electronic Medical Record (EMR) form titled ";Physician Certification for Hospice Benefits – Certification #1" dated from 8/5/2023 to 10/3/2023, MD1 stated he did not document on the certification of terminal illness (CTI) because he had been busy. MD1 stated there was no documentation of a face-to-face visit or Patient 8s history and physical. MD1 stated his documentation was based on the nursing assessment. 5.A review of Patient 10s medical record form titled ";Patient Information," indicated a start of care date of 1/27/2023 with a diagnosis of end stage heart failure (progressive heart failure). It also indicated MD3 was the referring MD. A record review of Patient 10s EMR form titled ";Nursing Re-Cert Assessment," dated 7/25/2023, indicated ";NYHA – IV – patients with cardiac disease resulting in inability to carry on physical activity is undertaken, discomfort is increased" was selected. It also indicated form was created by Registered Nurse 2 (RN2). A review of Patient 10s medical record form titled ";LCD Hospice Eligibility Determination" dated 7/25/2023, indicated ";heart disease (1 and 2 must be met); 2: NYHA classification – a. does this CHF or angina patient meet the criteria for NYHA Class IV level? YES". A review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefit," dated from 7/26/2023 to 9/23/2023, indicated MD1s signed the form. It also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." During an observation, interview, and a joint home visit on 8/29/2023 at 10:40 a.m., with Licensed Vocational Nurse 1 (LVN1) to Patient 10s home, LVN1 stated sometimes he (LVN 1) was unable to see Patient 10 because Patient 10 was not at home. LVN1 stated Patient 10 attended an adult day care center. Patient 10 was awake and alert and walked using a walker (is a type of mobility aid that offers stability and support while walking). Patient 10 stated he had not used the oxygen provided by the hospice agency because he did not get short of breath. Patient 10 stated he attended an adult day care center where he conducted ";mind and physical exercise." Patient 10 stated he performed all his activities of daily living (ADL – activities of daily living, essential and routine tasks), but he did not shower by himself. Patient 10 stated he had a primary physician (MD3) since 2007 but had not seen her because he had been in either hospice or home health since then. Patient 10 stated he had never been told he had six months or less to live. Patient 10 stated a marketer (MK) told him there were two types of hospice services, one for those who are bedridden and those who could attend adult day care centers. During a concurrent interview and record review on 8/30/2023 at 11:05 a.m. with MD1 of Patient 10s EMR form titled ";Physician Certification for Hospice Benefits – Certification #1" dated from 7/26/2023 to 9/23/2023, MD1 stated he certified Patient 10 for hospice care. MD1 stated his signature was on the record. MD1 stated he was not aware Patient 10 attended an adult day care center. MD1 stated his narrative under section ";Certifying Physician Summary" was based on the nurses assessment. MD1 stated there was no face-to-face visit documentation in Patient 10s EMR. 6. A review of Patient 12s medical record form titled ";Patient Information" indicated a start of care date of 2/17/2023 with diagnoses including cerebrovascular disease (stroke is a loss of blood flow to part of the brain). It also indicated MD1 was listed under ";referring/attending..." A review of Patient 12s medical record form titled ";LCD Hospice Eligibility Determination," dated 2/21/2023 and 7/20/2023, indicated ";Stroke and Coma – for A-Stroke 1 and 2 should be met." It also indicated, ";2. c. Current HX (history) of pulmonary aspiration not responding to speech language pathology intervention? (Sequential calorie counts documenting inadequate caloric/fluid intake): YES and d. Dysphagia severe enough to prevent patient from continuing fluids/food necessary to sustain life and patient does not receive artificial nutrition and hydration?: YES". A review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefit" dated from 5/18/2023 to 8/15/2023, indicated MD1 name was documented on ";Physician Name". It also indicated Intake Coordinator (IC) signed under ";Signature on file/verified by (IC)." Lastly, form indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." During a concurrent interview and record review on 8/30/2023 at 11:08 a.m. with MD1 of Patient 12s EMR form titled ";Physician Certification for Hospice Benefits – Certification #2" dated from 5/18/2023 to 8/15/2023, MD1 stated Patient 12 was not his patient. MD1 stated, ";Yes, my name is printed on the CTI, but I am not involved with this patient care. I did not give permission to anyone to use my name or sign for me... This is not my patient." 7. A review of Patient 13s medical record form titled ";Patient Information" indicated a start of care date of 2/24/2023 with diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris (decrease blood flow to the heart). During a concurrent interview and record review on 8/30/2023 at 11:12 a.m., with MD1 of Patient 13s EMR record titled ";Physician Certification for Hospice Benefits – Certification #3" dated from 8/23/2023 to 10/21/2023, the record indicated the narrative under section ";Certifying Physician Summary" was left blank. It also indicated MD1s name was listed under ";Medical Director...". Lastly, the record indicated it was not signed or dated by MD1. MD1 stated the record was not completed or signed by him. MD1 stated he did not have time to uploaded into the EMR system. MD1 stated he was unable to locate a face-to-face visit note. 8.A review of Patient 14s medical record form titled ";Patient Information," indicated a start of care date of 2/21/2023 with diagnosis of atherosclerotic heart disease of native coronary artery with angina pectoris (decrease blood flow to the heart). During a concurrent interview and record review on 8/30/2023 at 11:15 a.m., with MD1 of Patient 14s EMR record titled ";Physician Certification for Hospice Benefits – Certification #2" dated from 8/20/2023 to 10/18/2023, the record indicated the narrative under section ";Certifying Physician Summary" was left blank. It also indicated MD1s name was listed under ";Medical Director...". Lastly, the record indicated it was not signed or dated by MD1. MD1 stated he did not document on Patient 14s CTI. MD1 stated he was unable to locate a face-to-face visit documentation. MD1 stated, ";I base my narrative on the nurses assessment, I guess he is due for a recertification revisit." During an interview on 8/28/2023 at 3 p.m., with the Director of Nursing (DON), the DON stated in general, prior to the start of a patients recertification period, the interdisciplinary group (IDG, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities) would get together, and would discuss patients decline and the MD would make the decision whether to recertify the patient or not. During an interview on 8/28/2023 at 3 p.m. with the DON, the DON stated MD 1 based the CTI on the RNs assessment, their visit, and patients medical record. DON stated the CTI should be completed 14 days before and within two days of patient admission and before every recertification. DON stated the MD would sign the CTI to certify the patient met hospice criteria. DON stated either the MD or Nurse Practitioner (NP) needed to complete the face-to-face visit before the second recertification period ends and 14 prior to the third period. During a telephone interview on 8/30/2023 at 10:22 a.m., with MD1, MD1 stated he used the nursing assessments notes to approve or disapprove patients admission. MD1 stated he requested the patients history & physical, their medication list. MD1 stated he usually conducted the face-to-face visit via telehealth and that he would rarely see the patients at their home. MD1 stated he had a lot of work and that working at the hospice agency was a side job for him. MD1 stated he would go to the patients homes if he was close by. MD1 stated the hospice agency had an NP who would go to the patients home for the recertification. MD1 stated after the NP saw the patients, they would discuss the case and he then determined if the patient would continue with hospice services or not. MD1 stated there was an IDG meeting every two weeks where they discussed the patients. MD1 stated he documented his narrative under section ";Certifying Physician Summary" in the patients CTI form. MD1 stated his signature was electronic. MD1 stated he did not share his EMR logging information with anyone. A record review of the HAs policy and procedure titled, ";Interdisciplinary Group Meeting" undated, indicated ";Patient approaching recertification will be reviewed for the appropriates of continuation of care based on identifiable criteria and progression of the terminal illness." A record review of the hospice agencys policy and procedure titled, ";Comprehensive Assessment" undated, indicated ";The assessment should determine probable prognosis of six (6) months or less...". A record review of the hospice agencys policy and procedure titled, ";Certification of Terminal Illness" undated, indicated ";A subsequent recertification, at the beginning of each new benefit period, may be signed by the attending physician or the hospice Medical Director. A verbal or written certification statement must be obtained from the Medical Director or the attending physician no more that two (2) weeks prior or two (2) calendar days after the first day or each period. The signed and dated certification must be present prior to billing for each recertification period." A record review of the hospice agencys policy and procedure titled, ";Physician Services – Medical Director" undated, indicated ";The duties and responsibilities of the Medical Director will include, but not be limited to, the following: Reviewing patients medical eligibility for hospice services, in accordance with hospice program policies and procedures, and establishing the plan of care in conjunction with attending physician and interdisciplinary group prior to providing care, including written certification of terminal illness." A record review of the hospice agencys policy and procedure titled, ";Clinical Data Collection Review" undated, indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services." A record review of the hospice agencys policy and procedure titled, ";Admission Criteria and Process" undated, indicated ";The patients life-limiting illness and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determinations (LCDs). (HA) will admit a patient only on recommendation of the medical director in consultation with, or input from, the patients attending physician, if any... The patients physician must order and approve the provision of hospice care... The patient must desire hospice services and be aware of the diagnosis and prognosis... Eligibility criteria will be continually reviewed by the interdisciplinary team to ensure appropriateness of hospice care."

This Condition is not met as evidenced by: Based on interview, observation, 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 any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date, and authorship of each record modification for seven out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 10, and Patient 12). (Refer to L679). 2. The HA failed to ensure contents and information in the patients medical records were safeguarded from unauthorized access by HA staff and/or contracted staff to make any alterations or modifications for four out of 14 sampled patients (Patient 3, Patient 8, Patient 11, and Patient 12). (Refer to L680). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records are safeguarded from unauthorized access by any individuals or hospice staff.

Based on interview, observation, and record review, the hospice agency (HA) failed to ensure any amendments, correction or late entries within an electronic health record must clearly identify the original content, the modified content, date and authorship of each record modification for seven out of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 10, and Patient 12). This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients clinical record that could affect the patients quality of care and well-being. --- a. A record review of Patient 1s ";Personal Information", indicated a start of care on 7/5/2023, with a diagnosis of chronic obstructive pulmonary disease (a lung condition). During a concurrent interview and record review on 8/30/2023, at 12:11 p.m., the Director of Nursing (DON), reviewed Patient 1s record titled, ";Comprehensive Nursing Assessment", dated 7/5/2023. The DON stated the record indicated Registered Nurse 1 (RN 1) was the nurse who performed the initial comprehensive assessment on 7/5/2023. During an interview on 8/30/2023, at 12:17 p.m., RN 1 stated she did not do any of the initial comprehensive assessments for the HA. RN 1 stated she was not employed at the HA, has not signed any employment documents, and was shocked the HA was using her name in patients documents. RN 1 stated she did not know who Patient 1 was. During an interview on 8/30/2023, at 2:08 p.m., the DON stated she did not know RN 1 was not employed at the HA. The DON stated she did not know who saw Patient 1 for the initial comprehensive assessment. A record review of Patient 1s records titled, ";POC (Plan of Care)/IDG (Interdisciplinary Group)", dated 7/5/2023. indicated RN 1 was the author of the document. The HA failed to ensure P1s clinical records accurately reflected the author of the note. b. A record review of Patient 2s ";Personal Information", indicated a start of care on 6/16/2023, with a diagnosis of chronic obstructive pulmonary disease (a lung condition). During a concurrent interview and record review on 8/30/2023, at 2:22 p.m., the DON reviewed Patient 2s record titled, ";Comprehensive Nursing Assessment", dated 6/16/2023. The DON stated RN 1 was the author of the document. A record review of Patient 2s records indicated RN 1 was the author for the following documents: ";POC/IDG", dated 6/16/2023. ";POC/IDG", dated 6/22/2023. ";POC/IDG", dated 7/6/2023. ";Updated Assessment", dated 7/13/2023. The HA failed to ensure Patient 2s clinical records accurately reflected the author of the note. c. A record review of Patient 3s ";Personal Information", indicated a start of care on 3/8/2023, with a diagnosis of heart disease. During a concurrent interview and record review on 8/30/2023, at 2:27 p.m., the DON reviewed Patient 3s record titled, ";Re-Cert (recertification) Assessment", dated 3/8/2023. The DON stated RN 1 was the author of the document. The DON stated she did not know who documented the initial comprehensive assessment, because RN 1 did not work at the HA. The HA failed to ensure Patient 3s clinical record accurately reflected the author of the note. d. A record review of Patient 4s ";Personal Information", indicated a start of care on 1/27/2023, with a diagnosis of chronic obstructive pulmonary disease (a lung condition). During a concurrent interview and record review on 8/30/2023, at 2:30 p.m., the DON reviewed Patient 4s record titled, ";Comprehensive Nursing Assessment", dated 1/27/2023. Further review of the record indicated Registered Nurse 1 (RN 1) was the nurse who performed the initial comprehensive assessment on 1/27/2023. The DON stated she was assuming the assessment was not accurate because RN 1 did not work for the HA and did not see Patient 4. A record review of Patient 4s records indicated RN 1 was the author for the following documents: ";POC/IDG", dated 5/11/2023. ";POC/IDG", dated 5/25/2023. ";POC/IDG", dated 6/8/2023. ";POC/IDG", dated 6/22/2023. ";POC/IDG", dated 7/6/2023. ";Plan of Care", dated 8/28/2023. The HA failed to ensure Patient 4s clinical records accurately reflected the author of the note. e. A record review of Patient 5s ";Personal Information", indicated a start of care on 3/20/2023, with a diagnosis of hypertensive (high blood pressure) heart disease with heart failure. During a concurrent interview and record review on 8/30/2023, at 2:33 p.m., the DON reviewed Patient 5s record titled, ";Comprehensive Nursing Assessment", dated 3/20/2023. The record indicated Registered Nurse 1 (RN 1) was the nurse who performed the initial comprehensive assessment on 3/20/2023. The DON stated she was assuming the assessment was not accurate because RN 1 did not work for the HA and did not see Patient 5. The DON stated she did not know who documented the initial assessment and who assessed Patient 5. A record review of Patient 5s records indicated RN 1 was the author for the following documents: ";POC/IDG", dated 5/11/2023. ";POC/IDG", dated 5/25/2023. ";POC/IDG", dated 6/8/2023. ";POC/IDG", dated 6/22/2023. ";POC/IDG", dated 7/6/2023. ";Plan of Care", dated 8/28/2023. The HA failed to ensure Patient 5s clinical records accurately reflected the author of the note. f. A review of Patient 10s medical record form titled ";Patient Information", indicated a start of care date of 1/27/2023 with diagnoses including end stage heart failure (progressive heart failure). The record also indicated MD3 was the referring MD. A review of Patient 10s medical record form titled ";Physician Certification for Hospice Benefit – Statement for first 90-day period" dated from 1/27/2023 to 4/26/2023, indicated Medical Doctor 3s name was documented on ";Physician Name". The record also indicated Director of Nurses (DON) signed under ";Signature on file/verified by (DON)." The form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice..." During a joint home visit on 8/29/2023 at 10:40 a.m. with License Vocational Nurse 1 (LVN1) to Patient 10s home, Patient 10 stated that he has never been told that he had six months or less to live. During a phone interview on 8/29/2023 at 12:51 p.m. with MD3s nurse (MDN), MDN stated that they received a call from Patient 10's son on 12/2022, stating that Patient 10 was receiving hospice services. MDN stated that Patient 10 was seen by MD3 from 2010 to 2022. MDN stated that MD3 did not refer Patient 10 to hospice. g. A review of Patient 12s medical record form titled ";Patient Information", indicated a start of care date of 2/17/2023 with diagnoses including cerebrovascular disease (stroke, occurs when blood flow to the brain is blocked). It also indicated MD1 was listed under ";referring/attending..." A review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefit" dated from 5/18/2023 to 8/15/2023, indicated MD1's name was documented on ";Physician Name". The record also indicated Intake Coordinator (IC) signed under ";Signature on file/verified by (IC)." The record indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." During a concurrent interview and record review on 8/30/2023 at 11:08 a.m. with MD1 of Patient 12s EMR form titled ";Physician Certification for Hospice Benefits – Certification #2" dated from 5/18/2023 to 8/15/2023, MD1 stated that Patient 12 was not his patient. MD1 stated, ";Yes, my name is printed on the CTI, but I am not involved with this patient care. I did not give permission to anyone to use my name or sign for me... This is not my patient." A record review of the HAs undated policy and procedure titled, ";Access to Information", indicated ";Only authorized hospice personnel will have access to clinical and financial records. Access to patient information files will be limited to hospice personnel directly involved in the care of the patient and may include: Office personnel with need to know in order to perform their functions and processes, including intake personnel..." A record review of the HAs undated policy and procedure titled, ";Clinical Data Collection Review", indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services." A record review of the HAs undated policy and procedure titled, ";Safeguarding/Retrieval of Clinical Records", indicated ";Hospice will safeguard the clinical record against loss or unauthorized use.

Based on interview and record review, the Hospice Agency (HA) failed to ensure contents and information in the patients medical records were safeguarded from unauthorized access by HA staff and/or contracted staff to make any alterations or modifications for four out of 14 sampled patients (Patient 3, Patient 8, Patient 11, and Patient 12). This failure has the potential to result in an unauthorized and inaccurate patient information or assessment will be entered in the patients clinical record that could affect the patients quality of care and well-being. --- a. A record review of Patient 3s ";Personal Information", indicated a start of care on 3/8/2023, with a diagnosis of heart disease. During a concurrent interview and record review on 8/30/2023, at 1:15 p.m., the intake coordinator (IC) reviewed Patient 3s record titled, ";Physicians Certification for Hospice Benefit", for certification period 3/8/2023 to 6/5/2023. The record indicated, ";Medical Director Attestation/Certification: I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient. Signature on File/Verified by the IC." The IC stated Medical Doctor 2 (MD 2) told her to sign the document. The IC stated MD 2 had written the physician narrative. During a concurrent interview and record review on 8/30/2023, at 1:18 p.m., the IC reviewed Patient 3s record titled ";Audit Log", dated 3/8/2023 to 8/30/2023. The record indicated the IC documented on the physician narrative for certification period 3/8/2023 on 6/5/2023. The IC stated she was not aware of that and probably someone entered the information because it was not her. The HA failed to protect Patient 3s records against unauthorized access. b. A review of Patient 8s medical record form titled ";Patient Information", indicated a start of care date of 12/8/2022 with diagnoses including chronic obstructive pulmonary disease (COPD, a difficulty breathing). A review of Patient 8s medical form titled, ";Comprehensive Nursing Assessment" dated 12/8/2022, indicated ";signed by (Intake Coordinator – IC) (ADMN), to close note on behalf of staff assigned, Date 12/10/2022." It also indicated no other staff name was on form. A review of Patient 8s medical form titled, ";Re-Cert Assessment" dated 6/6/2023, indicated it was electronically signed by RN1. c. A review of Patient 11's medical record form titled ";Patient Information", indicated a start of care date of 7/12/2023 and an end of care date of 7/24/2023 with diagnoses including Alzheimers Disease (a degenerative brain tissue, memory loss). A review of Patient 11s medical form titled, ";Comprehensive Nursing Assessment" dated 7/12/2023, indicated it was signed by RN1. d. A review of Patient 12 medical record form titled ";Patient Information", indicated a start of care date of 2/17/2023 with diagnoses including cerebrovascular disease (stroke). The record also indicated Medical Doctor 1 (MD1) was listed under ";referring/attending..." During an interview on 8/28/2023 at 3:00 p.m. with the DON, the DON stated that RN1 was the DON designee while interviewing for the entrance conference. During a concurrent interview and record review on 8/30/2023 at 11:08 a.m., with MD1 of Patient 12s EMR form titled ";Physician Certification for Hospice Benefits – Certification #2" dated from 5/18/2023 to 8/15/2023, MD1 stated that Patient 12 was not his patient. MD1 stated, ";Yes, my name is printed on the CTI, but I am not involved with this patient care. I did not give permission to anyone to use my name or sign for me... This is not my patient." During an interview on 8/30/2023, at 12:11 p.m., RN 1 stated she did not do any of the initial comprehensive assessments for the HA. RN 1 stated she was not employed at the HA, has not signed any employment documents, and was shocked the HA was using her name in patients documents. During an interview on 8/30/2023, at 2:08 p.m., the DON stated she did not know RN 1 was not employed at the HA. During a concurrent interview and record on 8/30/2023 at 3:17 p.m., with Director of Nurses (DON) of Patient 12 medical record form titled ";Comprehensive Nursing Assessment", dated 2/21/2023, the DON stated she did not complete that form. DON stated that she changed her Electronic Medical Record (EMR) password ";sometime in March" because she noticed her name on other forms. DON stated that she does not know who documented the assessment and who electronically signed it. DON stated that she did not share her EMR login information with anyone. During an interview on 8/30/2023 at 3:35 p.m. with the Administrator (ADM), the ADM stated that RN1 emailed him her nursing credentials, but that she never worked for the HA. ADM stated that he is the one that issues all the employees their paychecks, and that RN1 never received a paycheck from the HA. ADM also stated that the IC was the only person who was able to provide EMR access to the HAs employees. ADM stated that he was not familiar with the EMR the HA uses. A record review of undated HAs ";Organizational Chart", indicated the RN1 was listed under ";DPCS (Director of Patient Care Services) Designee". A record review of undated HAs policy and procedure titled, ";Computer Access to Information", indicated ";passed code identification files will be secured and maintained in the Executive Director/Administrators or designees office. Information will be accessible only as appropriate to a particular terminal and its users." A record review of undated HAs policy and procedure titled, ";Access to Information", indicated ";Only authorized hospice personnel will have access to clinical and financial records. Access to patient information files will be limited to hospice personnel directly involved in the care of the patient and may include: Office personnel with need to know in order to perform their functions and processes, including intake personnel..." A record review of undated HAs policy and procedure titled, ";Clinical Data Collection Review", indicated ";Hospice will maintain a clinical record that is accurate, complete and reflects the care provided for all patients receiving services." A record review of undated HAs policy and procedure titled, ";Safeguarding/Retrieval of Clinical Records", indicated ";Hospice will safeguard the clinical record against loss or unauthorized use.

Observed in Record Review. In 5 of 5 patient records reviewed, the organization did not have some goals on the plans of care which were measurable. Examples include: patient/cg will achieve optimal grief reaction prior to patient's death, will have reduced stress levels and will utilize adequate coping skills; skin integrity will be maintained during care; patient will be maintained in safe environment, will achieve optimal sleep/rest. This was verified by the DPCS.

Observed in Record Review. In 5 of 5 patient records reviewed, the Spiritual Assessment was incomplete as defined in policy. Examples include: The patient was noted as Christian in the Spiritual Assessment and that a spiritual strength was personal faith experience however a Congregation or Clergy involved were not listed (HV1, HV 2). As noted in RR 1, the Spiritual assessment lists the patient as Christian, however there was no documentation of their congregation or clergy or request for their clergy to be notified if desired. The areas were left blank. The MSW assessment identified that there was involvement in a religious community, however there was no documentation of the names or as to whether they wanted them contacted. This was not consistent with the Spiritual Care Counseling Services policy which states ...if the patient, family/caregiver identifies involvement with a local church, synagogue, mosque, etc. and permission is given to contact them, the Hospice chaplain will call to coordinate care . In addition, the policy states that to meet CA Hospice standards, the Hospice must make reasonable efforts to arrange for visits of clergy or other individuals who can support the spiritual needs of the patient for patients who request such visits and must advise patients of this availability. Spiritual services include facilitating access to community spiritual resources. This was verified by the DPCS.