Every finding on record at God's Ways Hospice, Inc

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participations regarding Patient Rights was met as follows: --- The hospice failed to ensure patients and their legal representative must be informed of their rights and responsibilities, and informed consent to participate in the hospice program prior to receiving care for two of 14 sampled patients (Patient 3 and Patient 6). (Refer to L503). The cumulative effect of these systemic practices resulted in the failure of the Hospice to deliver statutorily mandated compliance with the Federal regulations for Patients Rights to ensure the highest quality of care are provided to patients certified to receive the Hospice care benefits.

Based on interview and record review the hospice failed to ensure patients and their legal representative must be informed of their rights and responsibilities, and informed consent to participate in the hospice program prior to receiving care for two of 14 sampled patients (Patient 3 and Patient 6). This deficient practice resulted in the violation of the patient bill of rights. --- 1. A review of Patient 3s ";Personal Information" sheet indicated a start of care date on 11/17/2023, with a primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). Further review of the record indicated the patient had a power of attorney (POA). During an interview on 7/12/2024, at 12:54 p.m., the Director of Patient Care Services (DPCS) stated the HA did not have a copy of Patient 3s POA on file. The DPCS stated it was important to have a copy of the POA, so staff will know who is legally authorized to make decision for the patient. During a concurrent interview and record review on 7/12/2024, at 12:54 p.m., the DPCS reviewed Patient 3s record titled, ";Election of Hospice Medicare Benefit and Authorization", dated 11/17/2023. The DPCS stated Patient 3 had signed the consents and he was not supposed to sign the consents due to his Alzheimers disease. The DPCS stated the POA was supposed to sign the consents because the patient did not have the mental capacity to make decisions for it. During a concurrent interview and record review on 7/12/2024, at 1:01 p.m., the DPCS reviewed Patient 3s record titled, ";Election of Hospice Medicare Benefit and Authorization". The DPCS stated he assumed the signature on the document belonged to the patient. The DPCS stated the signature was not legible and cannot be read to determine the name of the signature. The DPCS stated the signature did not indicate who specifically signed the document. The line where it was signed says ";signature of patient or legal representation". Without a POA, the DPCS could not verify if Patient 3 or the POA had signed the document. During an interview on 7/12/2024, at 1:09 p.m., Registered Nurse 1 stated she admitted Patient 3 into hospice care. RN 1 stated the patient did not have a POA and the caregiver was the one responsible for the patient. RN 1 stated the caregiver signed the consents. A record review of Patient 3s record titled, ";POA Information", dated 1/17/2023, indicated, a check mark next to ";I do have a ";Power of Attorney". 2. A review of Patient 6s, ";Personal Information" sheet indicated a start of care date on 9/24/2023, with an admitting diagnosis of hypertensive heart disease without heart failure (high blood pressure) and an end of care date was of 10/3/2023, with a discharge reason of death. The record further indicated a name (CG 1) was listed under section ";Authorized Rep" (authorized representative). The area in the sheet did not indicate a last name, address, and relationship to the patient. During an interview on 7/11/2024, at 1:30 p.m., CG 1 stated she was the primary caretaker for Patient 6. CG 1 stated she was not related to Patient 6. CG 1 stated an involved person (IP) reached out to her to provide a living place for Patient 6. The IP owned a facility, but CG 1 did not know what kind it was. CG 1 stated she gave Patient 6 a place to live and provided care for her for a ";very short period of time". CG 1 stated the IP would get hospice care for Patient 6. CG 1 stated there was no contact information for Patient 6s family when she initially came to her house. CG 1 stated Patient 6s niece reached out to her, and she was able to get Patient 6s family contact information, which she stated, provided to the HA. During an interview on 7/11/2024, at 2 p.m., the DPCS stated he did not know the IP. During an interview on 7/11/2024, at 2:06 p.m., the DPCS stated the primary contact person was CG 1 because Patient 6 did not have any family. The DPCS stated he knew about Patient 6 not having family through the nurses report. Patient 6s medical records did not indicate Patient 6 did not have family. The DPCS stated it was important to document the presence of family in Patient 6s record because the HA had to figure out what support system there was. If no support system in place, the social worker can intervene and give support systems. During a concurrent interview and record review on 7/11/2024, at 2:13 p.m., the DPCS reviewed Patient 6s record titled, ";Psychosocial Assessment", dated 9/25/2023. The record indicated ";MSW (Medical Social Worker) tried to contact family but declines psychosocial services at this time". When asked who did the MSW try to contact, the DPCS stated, ";Im not sure". Further review of the record indicated the note had been signed by the DPCS. The DPCS stated he signed the note because it was missing a signature. During an interview on 7/11/2024, at 2:17 p.m., the DPCS stated Patient 6 did not have a power of attorney (a legal document that appoints an individual to make decisions on behalf of the patient when the patient themselves cannot make decisions anymore). The DPCS stated Patient 6s medical records did not have information for mortuary arrangements. When asked where Patient 6s body went when she died, the DPCS stated the information was not specified on the discharge summary. The DPCS stated the HA did not have a death certificate for Patient 6. During an interview on 7/11/2024, at 2:28 p.m., the Office Coordinator (OC) stated there was no death certificate for Patient 6. The OC stated CG 1 authorized for Patient 6 to be cremated. During an interview on 7/11/2024, at 6:10 p.m., the IP stated he was not related to Patient 6. The IP stated a friend who owns a facility reached out to him to help find a living placement for Patient 6 because he could not handle her living at the home. The IP stated he found a living placement for Patient 6s at CG 1s back house and convinced her to move. The IP stated Patient 6 had a daughter whom she contacted frequently. The IP stated he spoke to Patient 6s daughter about moving to CG 1s home and the daughter had agreed to the move. The IP stated he had known CG 1 for a long period of time. The IP stated he did not know about Patient 6 being enrolled in hospice care and stated Patient 6 would have not agreed to that. The IP stated if Patient 6 was enrolled to hospice care, it was against her will. The IP stated he did not know what happened to Patient 6 and did not know where she was currently. During an interview on 7/12/2024, at 12:19 p.m., RN 1 stated she was the nurse who admitted Patient 6. RN 1 stated Patient 6 was alert, able to understand everything, and able to make her own decisions. RN 1 stated Patient 6 had signed the consents for hospice care. During a concurrent interview and record review on 7/12/2024, at 1:13 p.m. RN 1 reviewed Patient 6s record titled, ";Election of Hospice Medicare Benefit and Patient Authorization", dated 9/242023. RN 1 stated the name on the signature line said CG 1. RN 1 stated CG 1 was not Patient 6s name. RN 1 stated the Medical Director (MD 1) agreed for Patient 6 to be in hospice care. RN 1 stated CG 1 was Patient 6s legal representative because CG 1 said she was. When asked what the process should be when a patient is unable to sign for themselves, RN 1 stated patients should have a power of attorney (POA) and if they dont have one, the doctor needs to be signing the consents. RN 1 stated the importance of a POA was so the person who has legal authority is the one responsible in making decisions for the patient. The POA ensures the patients rights are respected. During an interview on 7/12/2024, at 2:11 p.m., the DPCS stated CG 1 should have not signed the admission consents if she was not legally the POA. The DPCS stated he was not 100 percent sure if caregivers were allowed to sign on behalf of patients. When asked what resources he could have used if he did not know who can legally sign documents for patients, the DPCS stated he could have reached out to the consultant, look at policy and procedure. The DPCS stated he did not use his resources because he did not pay attention to who had signed Patient 6s admission consents. The DPCS saw that the forms were signed. During a concurrent interview and record review on 7/12/2024, at 2:12 p.m., the DPCS reviewed Patient 6s record titled, ";Election of Hospice Medicare Benefit and Patient Authorization", dated 9/242023. The DPCS stated the document indicated CG 1 made the decision to put the patient in hospice care. The fact that the patient expired, shows the patient needed the service. The DPCS stated he was not sure if the patient wanted the service but was sure the patient needed the service. The DPCS stated Patient 6s right of informed consent was violated. The risk of this violation was Patient 6 not giving authorization to receive hospice services. During a concurrent interview and record review on 7/12/2024, at 2:23 p.m., the OC reviewed Patient 6s document titled, ";SoCal Cremations and Funerals", dated 10/2/2023. The document indicated the IPs name online titled, ";City". The OC stated the IP signed the cremation papers. The OC stated the IP lied to the funeral service saying he was family, but he was not family to Patient 6. The OC stated the HA tried to contact Patient 6s family. The OC stated there was no documentation on Patient 6s records about the attempts to contact the family. During an interview on 7/12/2024, at 2:40 p.m., the funeral services representative (REP) stated RN 1 called them when Patient 6 expired and provided the IPs name. The REP stated they (the funeral company) was told that the IP was Patient 6s cousin. The REP stated they were given contact information about Patient 6s family by the IP. During a record review of the HAs policy and procedure titled, ";Informed Consent/Refusal of Treatment", dated November 2021, indicated, ";Policy...4. During the admission visit, the patient or authorized representative will sign the organizations written consent for care/service...Procedure...3. Every attempt will be made to include, to the extent possible, available family/caregiver(s) in rendering care and meeting patient-specific goals of care." During a record review of the HAs policy and procedure titled, ";Informed Consent for Patient and Family/Caregiver", dated November 2021, indicated, ";Policy: The patient or his/her legal representative (when the patient is not competent or of legal age) must sign a consent to participate in a hospice program prior to receiving care." During a record review of the HAs policy and procedure titled, ";Advance Directives", dated November 2021, indicated, ";Procedure...2. If the patient lacks a decision-making capacity, the admitting clinician/technician will provide information and direct inquiry about Advance Directives to the patients representative...4. During the admission/evaluation visit, the admitting clinician/technician will ask the patient or his/her representative whether or no he/she has completed an Advance Directive, Durable Power of Attorney (DPOA), living will, or DNR/DNI order. If an Advance Directive has been completed, the clinician/technician will ask for a copy of the Advance Directive so it will be placed in the clinical/service record."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participations for Initial and Comprehensive Assessments of Patients was met as follows: --- 1. The HA failed to conduct an initial assessment that reflected the patients current health status and identify patients need for hospice care and services related to hospice eligibility and management of terminal illness for one of 14 sample selected patients (Patient 4). This failure resulted in the delay in identifying patient's needs and services including the essential information necessary to formulate the plan of care and provide the immediate necessary care and services. (Refer to L 522). 2. The HA failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient.) complete the comprehensive assessment no later than 5 calendar days after election for six of 14 sampled patients (Patient 2, Patient 5, Patient 8, Patient 11, Patient 12, and Patient 14). This failure had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. (Refer to L 523). 3. The HA failed to ensure the comprehensive assessment identified the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that addressed the hospice patient's well-being, comfort, and dignity throughout the dying process for three of 14 patients (Patient 8, Patient 10, and Patient 12). This failure had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. (Refer to L 524). 4. The HA failed to ensure an initial bereavement assessment was done for four of 14 sample selected patients (Patient 4, Patient 5, Patient 8, and Patient 12), which 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. This failure had the potential for the patient/family not being provided social, spiritual, and cultural support related to the patient's death. (Refer to L 531). 5. The HA failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met and updated the comprehensive assessment at least every 15 days for eleven out of 14 sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 14). This deficient practice had the potential for the IDG not able to evaluate and document the patients response to the care, treatment and services provided, and progress toward desired outcomes including changes in patient/family condition or needs affecting their quality of care. (Refer to L 533). The cumulative effect of these systemic practices resulted in the failure of the Hospice to deliver statutorily mandated compliance with the Federal regulations for Initial & Comprehensive Assessment of Patient to ensure the highest quality of care are provided to patients certified to receive the Hospice care benefits.

Based on interview, and record, the Hospice Agency (HA) staff failed to conduct an initial assessment that reflected the patients current health status and identify patients need for hospice care and services related to hospice eligibility and management of terminal illness for one of 14 sample selected patients (Patient 4). This failure resulted in the delay in identifying patient's needs and services including the essential information necessary to formulate the plan of care and provide the immediate necessary care and services. --- A review of Patient 4s record titled, ";Personal Information", indicated a start of care on 4/25/2024, with a primary diagnosis of heart disease. During a concurrent interview and record review on 7/12/2024, at 1:41 p.m., the Director of Patient Care Services (DPCS) reviewed Patient 4s record titled, ";Comprehensive Nursing Assessment", dated 5/1/24. The record indicated the initial assessment visit was done on 5/1/2024. The DPCS stated the nurse was supposed to visit the patient within 5 days. As a result, the plan of care (POC) was late because the assessments were late. The DPCS stated the POC was created 5/28/24. During a record review of facilitys policy and procedure titled, ";Initial Assessment" revised November 2021, indicated ";An initial assessment will be performed by a registered nurse within 48 hours after election of hospice care... To provide guidelines for the initial assessment to evaluate the patients physical, psychosocial, and emotional needs and determine immediate care and support needs." During a record review of facilitys policy and procedure titled, ";The Plan of Care" revised November 2021, indicated ";The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group... This plan must be initiated at start of care. 4. The plan of care... must state, in detail, the scope and frequency of services needed... 5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care." During a record review of facilitys policy and procedure titled, ";Admission Criteria and Process" revised November 2021, indicated ";15. The hospice registered nurse will complete and initial assessment during this visit within 48 hours after the election of hospice care. During a record review of facilitys policy and procedure titled, ";Clinical/Service Date Collection" revised November 2021, indicated ";Documentation in the clinical/service 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 the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient.) complete the comprehensive assessments no later than 5 calendar days after election for 6 of 14 sampled patients (Patient 2, Patient 5, Patient 8, Patient 11, Patient 12, and Patient 14). This failure had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- During an interview on 7/9/2024, at 1:26 p.m., the Director of Patient Care Service (DPCS) stated the Medical Social Worker (MSW) was supposed to do the initial psychosocial assessment within 5 days of the start of care, monthly, and on recertification, unless the patient denies the assessment. The DPCS stated the documentation was supposed to be completed within 5 days, to include the signature. The purpose of the psychosocial assessment was to assess patients psychosocial needs, to see if they are there mentally, to see if their housing is okay, to see if they need advanced directive, home health support services, meals on wheels, and to assess which resources they need. The DPCS stated if the assessment was not done, the quality of care will be affected because there might be some issues not addressed, which is not okay. During an interview on 7/9/2024, at 1:30 p.m., the DPCS stated the spiritual counselor (SC) was responsible for completing patients spiritual assessments within 5 days of their start of care. The spiritual assessment was important because patients are dying, they will have other needs different than the alive patients. They might have religious needs, ask about spirituality. We want to identify those needs and intervene/help them. If a spiritual assessment is not done, patients are not going to have end of life needs tailored to. SCs provide patients peace of mind and psychosocial support as well. They help them resolve with issues they might have. During an interview on 7/11/2024 at 12:15 p.m., the DPCS stated the HA team get together during a patients comprehensive assessment to discuss patients care needs. The DPCS stated patients can have poor quality of care or not receive the best care because not every issue will be addressed when they do not have a comprehensive assessment. 1. A review of Patient 2s record titled, ";Personal Information", indicated a start of care date of 3/27/2024, with a diagnosis of heart disease. During a concurrent interview and record review on 7/12/2024, at 12:48 p.m., the DPCS reviewed Patient 2s records. The DPCS stated the assessment was supposed to be documented under the assessment tab, specifically psychosocial, in the electronic medical record (EMR). The DPCS stated the assessment was not done by the MSW and did not know why it was not done. The DPCS stated Patient 2 had not declined the assessment. It was important for Patient 2 to have a psychosocial assessment to now her needs, to see what her support system is, if she has access to water, electricity, and to know what her emergency preparedness needs are. 2. A review of Patient 5s record titled, ";Personal Information", indicated a start of care date on 3/28/2024, with a diagnosis of end stage heart failure (heart losing its ability to pump blood to the body effectively). During a record review of Patient 5s EMR, on 7/9/2024, at 3:09 p.m., the assessment tab ";spiritual" did not indicate a spiritual assessment. During a concurrent interview and record review on 7/12/2024, at 1:29 p.m., the DPCS reviewed Patient 5s records. The DPCS stated the assessment was supposed to be documented under the assessment tab, specifically spiritual, in the EMR. The DPCS stated the spiritual assessment was in the medical records and was entered on 7/10/2024. The DPCS stated the SC did not document the assessment on time and did not know the reason why. The DPCS stated the spiritual assessment was needed to ensure the spiritual needs were identified and interventions done to meet those needs. 3. During a review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 6/7/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 8s medical record form titled ";POC/IDG Review" dated 6/7/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a concurrent interview and record review on 7/11/2024 at 12;15 p.m. with the Director of Patient Care Services (DPCS) of Patient 8s medical record, DPCS stated based on the lack of signatures on Patient 8s comprehensive assessment, Patient 8 did not have a comprehensive assessment. 4. During a review of Patient 11s medical record form titled ";Personal Information" indicated a start of care date of 4/26/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 11s medical record form titled ";POC/IDG Review" dated 4/26/2024, indicated the nursing documentation section was left blank. The form also indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a concurrent interview and record review on 7/12/2024 at 1:20 p.m. with the DPCS of Patient 11s medical record, the DPCS stated Patient 11s comprehensive assessments dated 6/10/2024, 6/24/2024, and 7/8/2024, were not completed or signed by the IDG members. 5. During a review of Patient 12s medical record form titled ";Personal Information" indicated a start of care date of 5/1/2024, with a diagnosis of heart disease, unspecified. During a review of Patient 12s medical record form titled ";POC/IDG Review" dated 5/1/2024, indicated the nursing discussion section was left blank. The form also indicated it was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a concurrent interview and record review on 7/12/2024 at 1:24 p.m. with the DPCS of Patient 12s medical record, DPCS stated there was nothing documented in Patient 12s initial comprehensive assessment due to possible formulation of the comprehensive assessment before there were patient issues added. DPCS stated Patient 12 did not have an initial comprehensive assessment. DPCS stated Patient 12 did not have a referral for hospice order in the medical record. DPCS stated Patient 12 was not certified by a physician for hospice services from 5/1/2024 till the last 24 hours. DPCS stated Patient 12 did not receive the ";best" evaluation for hospice care. DPCS stated he did not know if Patient 12 qualified for hospice services based on the medical record. 6. During a review of Patient 14s medical record form titled ";Personal Information" indicated a start of care date of 11/14/2023, an end of care date of 6/19/2024, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque buildup in the heart artery causing narrowing of the artery without chest pain). During a review of Patient 14s medical record form titled ";POC/IDG Review" dated 11/14/2023, indicated the form was not signed by the medical doctor and chaplain. During a record review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised November 2021, indicated ";A comprehensive patient assessment will be performed by the interdisciplinary group no later than 5 calendar days after the election of hospice care in consultation with attending physician. 1. During the comprehensive patient assessment, all baseline data and other relevant information will be documented...2. The assessment should determine probable prognosis of six (6) months or less. 4. The Clinical Supervisor will be responsible for assuring that the documentation of clinical findings supports the terminal diagnosis." During a record review of facilitys policy and procedure titled, ";The Plan of Care" revised November 2021, indicated ";The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group ... This plan must be initiated at start of care...5. The individualized plan of care will be reviewed by the rest of the interdisciplinary group within two (2) days of start of care." During a record review of facilitys policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" revised November 2021, indicated ";The hospice interdisciplinary team/group members will include, at a minimum: A. Physician. B. Registered Nurse. C. Social Worker. D. Pastoral or other counselor. The interdisciplinary group responsibilities include but are not limited to: A. Participate in the establishment of the plan of care for each patient admitted..." During a record review of facilitys policy and procedure titled, ";Clinical/Service Date Collection" revised November 2021, indicated ";Documentation in the clinical/service 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 the comprehensive assessment identified the physical, psychosocial, emotional, and spiritual needs related to the terminal illness that addressed the hospice patient's well-being, comfort, and dignity throughout the dying process for three of 14 patients (Patient 8, Patient 10, and Patient 12). This failure had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life. --- 1. During a review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 6/7/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 8s medical record form titled ";Spiritual Assessment" dated 6/10/2024, indicated the assessment form was left blank and it did not have a signature. During a review of Patient 8s medical record form titled ";Current Treatment/Medication/DME List", indicated ";Spiritual Care Coordinator for Spiritual assessment within 5 days of admission to identify spiritual needs/support to patient, family and primary caregiver." During a concurrent interview and record review on 7/11/2024 at 12;15 p.m. with the Director of Patient Care Services (DPCS) of Patient 8s medical record, DPCS stated the copy of Patient 8s initial spiritual assessment provided on 7/10/2024 by the Office Coordinator (OC), was not completed. DPCS stated the Spiritual Counselor ";probably completed it last night". 2. During a review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 7/16/2023, with a diagnosis of Alzheimers Disease (progressive memory loss). During a review of Patient 10s medical record form titled ";Spiritual Assessment" dated 5/7/2024, indicated assessment form was left blank and it did not have a signature. During a review of Patient 10s medical record form titled ";Current Treatment/Medication/DME List", indicated ";Spiritual care coordinator for spiritual assessment within 5 days of admission to identify spiritual needs/support to patient, family, and primary care giver." During a concurrent interview and record review on 7/12/2024 at 1:10 p.m. with the DPCS of Patient 10s medical record, DPCS stated Patient 10 did not have a recertification spiritual assessment. DPCS stated ";there should have been a recertification spiritual assessment on 7/10/2024." 3. During a review of Patient 12s medical record form titled ";Personal Information" indicated a start of care date of 5/1/2024, with a diagnosis of heart disease, unspecified. During a review of Patient 12s medical record form titled ";Spiritual Assessment" dated 5/4/2024, indicated assessment form was left blank and it did not have a signature. During a review of Patient 12s Electronic Medical Record (EMR) medical record form titled ";History of Psychosocial Assessment" undated, indicated there were no entries made. During a review of Patient 12s medical record form titled ";Current Treatment/Medication/DME List", indicated ";Spiritual Care Coordinator for Spiritual assessment within 5 days of admission to identify spiritual needs/support to patient, family and primary caregiver." The assessment form also indicated ";Medical Social Worker initial assessment within 5 days of admission to assess for psychosocial needs." During a concurrent interview and record review on 7/12/2024 at 1:24 p.m. with the DPCS of Patient 12s medical record, DPCS stated there was nothing documented in Patient 12s initial comprehensive assessment. DPCS stated Patient 12s spiritual assessment was not completed or signed. DPCS stated Patient 12 did not have a psychosocial assessment documented. During an interview on 7/9/2024 at 1:28 p.m. with the DPCS, the DPCS stated the Medical Social Worker completes and documents patients psychosocial assessments within 5 days or admission. DPCS stated patients psychosocial assessments are needed to identify if patients are there mentally, their living conditions, and if they require access to needed resources. DPCS stated ";If there is no psychosocial assessment the quality of care will be less because they might have issues that are not being addressed." During an interview on 7/9/2024 at 1:30 p.m. with the DPCS, the DPCS stated the Chaplain completes and documents patients spiritual assessments within 5 days of admission, as needed, and at patients recertifications. DPCS stated when patients refuse spiritual services, the Chaplain completes a phone call to explain and offer their services. DPCS stated patients require a spiritual assessment because they are at their end of life. DPCS stated patients end of life needs will not be tailored if they do not have a spiritual assessment to identify their needs. During an interview on 7/12/2024 at 2:15 p.m. with the SC, the SC stated his role was to provide spiritual, emotional, and bereavement support to patients and their families. SC stated he assesses patients initially, if requested, and at every recertification if needed. SC stated he has 5 days after patients start of care to complete and document their spiritual and bereavement assessments. During an interview on 7/12/2024 at 2:30 p.m. with the Medical Social Worker (MSW), the MSW stated her role is to complete and document patients initial psychosocial assessments within 5 days of start of care and at recertifications. MSW stated ";I document my assessment as soon as possible after the visit, but sometimes I delay the process. I sign my documentation once its completed." During a record review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised November 2021, indicated ";1. During the comprehensive assessment patient assessment, all baseline data and other relevant information will be documented in the patients clinical record...as relevant... S. The patients psychosocial status... T. An assessment of the patients and family/caregivers spiritual orientation... W. A bereavement assessment of the needs of the patients family..." During a record review of facilitys policy and procedure titled, ";The Plan of Care" revised November 2021, indicated ";The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days... This plan must be initiated at start of care... 12. The written plan of care will contain... E. Identification of patient and family/caregiver needs, including... psychosocial... spiritual...bereavement..." During a record review of facilitys policy and procedure titled, ";Spiritual Assessment" revised November 2021, indicated ";2. The Hospice Chaplain will contact the patient/family by a home visit or by telephone based on the patients and familys needs and acceptance of these services. 3. If the patient and family/caregiver refuse these services, the refusal will be documented. The interdisciplinary group members will continue to assess for spiritual needs... 4. The in-depth spiritual assessment will be performed by the Hospice Chaplain... 6. The assessment will be completed and placed in the patients clinical record." During a record review of facilitys policy and procedure titled, ";Psychosocial Assessment" revised November 2021, indicated ";1. A social work contact will be made either by a home visit or by telephone based on the patients and familys needs and acceptance of these services. 2. A psychosocial assessment will be performed at the initial meeting of patient and family/caregiver... 8. If the patient and/or family/caregiver refuses psychosocial visits, patient and family/caregiver needs will continue to be assessed on an ongoing basis."

Based on interview and record review the Hospice Agency (HA) failed to ensure an initial bereavement assessment was done which 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 four of 14 patients (Patient 4, Patient 5, Patient 8, and Patient 12). This failure had the potential for the patient/family not being provided social, spiritual, and cultural support related to the patient's death. --- During an interview on 7/9/2024 at 1:35 p.m., the Director of Patient Care Services (DPCS) stated the Chaplain was responsible for conducting and documenting patients bereavement assessments within 5 days of their start of care. The DPCS stated when patients decline bereavement assessments, the Chaplain is required to call the patient or their family to explain and offer their services. The DPCS stated it was important to provide patients bereavement assessments because they and their families will be grieving. The DPCS stated patients and their families ";have no one to share what they are going through; we need to help out the family as much as the patient. We have to assess how the caregiver is dealing with their dying relative." During an interview on 7/12/2024 at 2:15 p.m., the SC stated his role was to provide spiritual, emotional, and bereavement support to patients and their families. The SC stated he assessed patients initially, if requested, and at every recertification if needed. The SC stated he had 5 days after patients start of care to complete and document their spiritual and bereavement assessments. 1. A review of Patient 4s record titled, ";Personal Information", indicated a start of care on 4/25/2024, with a primary diagnosis of heart disease. During a concurrent interview and record review on 7/12/2024, at 1:36 p.m., the DPCS reviewed Patient 4s records. The DPCS stated the initial bereavement assessment was supposed to be documented in the electronic medical record (EMR) under the bereavement tab. The DPCS stated there was no bereavement assessment for Patient 4 and did not know why. It was important to have an assessment to see how patients and their families were dealing with the whole situation. 2. A review of Patient 5s record titled, ";Personal Information", indicated a start of care date on 3/28/2024, with a diagnosis of end stage heart failure (heart losing its ability to pump blood to the body effectively). During a record review of Patient 5s EMR, on 7/9/2024, at 3:09 p.m., the assessment tab ";bereavement" did not indicate a bereavement assessment. During a concurrent interview and record review on 7/12/2024, at 1:37 p.m., the DPCS reviewed Patient 5s records. The DPCS stated the initial bereavement assessment was in the EMR and had been documented on 7/10/2024. 3. During a review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 6/7/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 8s Electronic Medical Record (EMR) medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a review of Patient 8s medical record form titled ";Current Treatment/Medication/DME List", indicated ";Bereavement coordination to assess and evaluate bereavement and grieving risk factors within 5 days of admission." During a concurrent interview and record review on 7/11/2024 at 12:15 p.m. the DPCS reviewed Patient 8s medical record and stated that the Spiritual Counselor completed his documentation after 7/9/2024. During an interview on 7/12/2024 at 2:15 p.m. with the Spiritual Counselor (SC), the SC stated he was not aware Patient 8 was readmitted. SC stated he does not know when he visited Patient 8. 4. During a review of Patient 12s medical record form titled ";Personal Information" indicated a start of care date of 5/1/2024, with a diagnosis of heart disease, unspecified. During a review of Patient 12s Electronic Medical Record (EMR) medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a review of Patient 12s medical record form titled ";Current Treatment/Medication/DME List", indicated ";Bereavement coordination to assess and evaluate bereavement and grieving risk factors within 5 days of admission." During a concurrent interview and record review on 7/12/2024 at 1:24 p.m. with the DPCS of Patient 12s medical record, DPCS was provided Patient 12s History of Bereavement Assessment medical record copy. DPCS stated Patient 12 did not have a bereavement assessment documented. During a record review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised November 2021, indicated ";1. During the comprehensive assessment patient assessment, all baseline data and other relevant information will be documented in the patients clinical record...as relevant... W. A bereavement assessment of the needs of the patients family and other individuals..." During a record review of facilitys policy and procedure titled, ";The Plan of Care" revised November 2021, indicated ";The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days... This plan must be initiated at start of care... 12. The written plan of care will contain... E. Identification of patient and family/caregiver needs, including... psychosocial... spiritual...bereavement..." During a record review of facilitys policy and procedure titled, ";Bereavement Assessment" revised November 2021, indicated ";The hospice bereavement plan of care will be developed based on an initial assessment of the patient and family/caregiver needs, during the course of care, and at the time of the patients death as part of the comprehensive assessment. On admission, the social worker or hospice registered nurse will complete a bereavement risk assessment that is given to the Bereavement Coordinator. The bereavement counselor will review the bereavement risk assessment to determine potential needs of the survivors. The Bereavement Coordinator or Volunteer will document the family bereavement interventions. Upon completion all bereavement documentation will be filed.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met and updated the comprehensive assessment at least every 15 days for eleven out of 14 sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 14). This deficient practice had potential for the IDG not able to evaluate and document the patients response to the care, treatment and services provided, and progress toward desired outcomes including changes in patient/family condition or needs affecting their quality of care. --- During an interview on 7/9/2024 at 1:20 p.m., the Director of Patient Care Services (DPCS) stated he led the IDG meetings once every two weeks in the office or virtually. The DPCS stated first IDG meetings are conducted virtually or face time. The DPCS stated the IDG members responsibilities include conducting comprehensive assessments, documenting their findings, and submitting them within 5 days. The DPCS stated the Spiritual Counselor (SC), and the Medical Social Worker (MSW) were responsible for documenting their discussions in the IDG. The DPCS stated he transcribed the Medical Doctors and at times the Registered Nurses IDG discussion sections. The DPCS stated the team members signatures validated their attendance and participation during the patients IDG meetings. During an interview on 7/11/2024 at 12:15 p.m. with the DPCS stated they had 5 days to document their IDG meetings. The DPCS stated IDG members signatures verified their attendance and their review of the discussions. The DPCS stated the HA did not have any verification the IDG members attended the patients IDG meetings. During an interview on 7/12/2024 at 2:15 p.m., the SC stated he had been working at the HA for a few months and was part of the IDG team. The SC stated he had attended two IDG meetings since working at HA, which was receiving a phone call from an HA staff member to discuss the patients. The SC stated he did not document in the HAs EMR (Electronic Medical Record) IDG section. The SC stated, ";you would have to talk to the office on what and how they do their documentation." The SC stated the last time he attended an HAs IDG meeting was two months ago because he had not received any notifications of IDGs. During an interview on 7/12/2024 at 2:30 p.m., the MSW stated she was an IDG member. The MSW stated IDG meetings were held once a week and sometimes over Zoom (a video-telephone method of communication). The MSW stated she was available via Zoom or face time (a video-telephone method of communication) due to working somewhere else. The MSW stated she logged into the HAs EMR while attending the IDG meetings to document and sign her portion. The MSW was asked about the sampled patients that do not have psychosocial assessments. The MSW stated ";I am not doing a very good job, its my fault. Sometimes I forget to sign the IDG on the bottom." 1. A review of Patient 1s record titled, ";Personal Information", indicated a start of care date on 3/27/2024, with a diagnosis of hypertensive (high blood pressure) heart disease with heart failure (heart inability to pump blood effectively to the body). A record review of Patient 1s records titled ";POC/IDG", for dates 5/13/2024, 5/27/2024, 6/24/2024, and 7/8/2024, did not have any signatures of the IDG members to validate their attendance and input in the update of the comprehensive assessment. The record dated 6/24/2024 did not have any nursing input documented and the record dated 7/8/2024 did not have any IDGs members input documented. 2. A review of Patient 2s record titled, ";Personal Information", indicated a start of care date of 3/27/2024, with a diagnosis of heart disease. A record review of Patient 2s records titled ";POC/IDG", for dates 5/13/2024, 5/27/2024, 6/24/2024, and 7/8/2024, did not have any signatures of the IDG members to validate their attendance and input in the update of the comprehensive assessment. The record dated 6/24/2024 did not have any nursing input documented and the record dated 7/8/2024 did not have any IDGs members input documented. 3. A review of Patient 3s ";Personal Information" sheet indicated a start of care date on 11/17/2023, with a primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a concurrent interview and record review on 7/12/2024, at 12:50 p.m., the DPCS reviewed Patient 3s records. The DPCS stated the re-certification psychosocial assessment was supposed to be documented under the assessment tab, specifically psychosocial, in the electronic medical record (EMR). The DPCS stated the re-certification assessment was not done because the MSW either did not visit or visited the patient but did not document the visit. The DPCS stated a re-certification psychosocial assessment was important because that was the plan of care, you have to adhere to it, or you need to revise the plan of care. The risks of not doing an assessment were that the patients psychosocial needs will not be met. A record review of Patient 3s records titled ";POC/IDG", for dates 6/10/2024, 6/24/2024, and 7/8/2024, did not have any signatures of the IDG members to validate their attendance and input in the update of the comprehensive assessment. The record dated 6/24/2024 did not have any nursing input documented and the record dated 7/8/2024 did not have any IDGs members input documented. 4. A review of Patient 4s record titled, ";Personal Information", indicated a start of care on 4/25/2024, with a primary diagnosis of heart disease. A record review of Patient 4s records titled ";POC/IDG", for dates 6/10/2024, 6/24/2024, and 7/8/2024, did not have any signatures of the IDG members to validate their attendance and input in the update of the comprehensive assessment. The record dated 6/24/2024 did not have any nursing input documented and the record dated 7/8/2024 did not have any IDGs members input documented. 5. A review of Patient 5s record titled, ";Personal Information", indicated a start of care date on 3/28/2024, with a diagnosis of end stage heart failure (heart losing its ability to pump blood to the body effectively). During a record review of Patient 5s EMR, on 7/9/2024, at 3:09 p.m., the assessment tab ";spiritual" did not indicate a spiritual assessment. During a concurrent interview and record review on 7/12/2024, at 1:29 p.m., the DPCS reviewed Patient 5s records titled, ";Spiritual Assessment", dated 3/20/204 and 6/23/2024. The DPCS stated the spiritual assessment was in the medical records and was entered on 7/10/2024. The DPCS stated the SC did not document the assessment on time and did not know the reason why. The DPCS stated the spiritual assessment was needed to ensure the spiritual needs were identified and interventions done to meet those needs. The DPCS stated based on what was written in the assessments, the patient should have a plan of care that addresses her spiritual needs because he wrote the patient was sad. The note also said the patient wished to have community religious groups visit her. The DPCS then reviewed Patient 5s records titled, ";POD/IDG", dated 6/10/2024, 6/24/2024, and 7/8/2024. The DPCS stated the IDG meetings did not have her spiritual wishes addressed. A record review of Patient 5s records titled ";POC/IDG", for dates 6/10/2024, 6/24/2024, and 7/8/2024, did not have any signatures of the IDG members to validate their attendance and input in the update of the comprehensive assessment. The record dated 6/24/2024 did not have any nursing input documented and the record dated 7/8/2024 did not have any IDGs members input documented. 6. During a review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 6/7/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 8s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 8s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During an interview on 7/11/2024 at 12:15 p.m. with the DPCS, the DPCS stated Patient 8s IDG meeting dated 7/8/2024 was not completed. 7. During a review of Patient 9s medical record form titled ";Personal Information" indicated a start of care date of 5/27/2024, with a diagnosis of heart disease, unspecified. During a review of Patient 9s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 9s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing discussion section was left blank. The form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 9s medical record form titled ";POC/IDG Review" dated 6/10/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a concurrent interview and record review on 7/11/2024 at 1 p.m. with the DPCS of Patient 9s medical record, the DPCS stated Patient 9s IDG meetings dated 6/10/24, 6/24/2024, 7/8/2024, were not signed. DPCS stated ";How hard is it to click on the page." 8. During a review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 7/16/2023, with a diagnosis of Alzheimers Disease (progressive memory loss). During a review of Patient 10s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 10s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing discussion section was left blank. The form also indicated it was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 10s medical record form titled ";POC/IDG Review" dated 5/27/2024 and 6/10/2024, indicated the forms were not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a concurrent interview and record review on 7/12/2024 at 1:10 p.m. with the DPCS of Patient 10s medical record, the DPCS stated Patient 10s IDG meeting registered nurse discussion section dated 6/24/2024 was completed within the last 24 hours by him from the registered nurse notes completed on 6/16/2024. DPCS stated he did not indicate the documentation as a late entry. DPCS stated he need to document a late entry for quality assurance purposes and to keep track of timely submissions. DPCS stated Patient 10s IDG meeting dated 7/8/2024, he was the one who documented under the registered nurse and other/physician discussion sections. 9. During a review of Patient 11s medical record form titled ";Personal Information" indicated a start of care date of 4/26/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 11s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 11s medical record form titled ";POC/IDG Review" dated 6/10/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 11s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing documentation section was left blank. The form also indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a concurrent interview and record review on 7/12/2024 at 1:20 p.m. with the DPCS of Patient 11s medical record, the DPCS stated Patient 11s comprehensive assessments dated 6/10/2024, 6/24/2024, and 7/8/2024, were not completed or signed by the IDG members. 10. During a review of Patient 12s medical record form titled ";Personal Information" indicated a start of care date of 5/1/2024, with a diagnosis of heart disease, unspecified. During a review of Patient 12s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. The form also indicated it was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 12s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing discussion section was left blank. The form also indicated it was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a concurrent interview and record review on 7/12/2024 at 1:24 p.m. with the DPCS of Patient 12s medical record, DPCS stated Patient 12s IDG meeting dated 6/24/2024 did not have her problems, interventions, and goals listed because he forgot to click the button that imports that information on to the form. DPCS stated Patient 12s IDG meeting dated 7/8/2024, was completed within the last 24 hours. 11. During a review of Patient 14s medical record form titled ";Personal Information" indicated a start of care date of 11/14/2023 and end of care date of 6/19/2024, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque in the heart artery causing narrowing of artery without chest pain). During a review of Patient 14s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 14s medical record form titled ";POC/IDG Review" dated 6/10/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 14s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing discussion section was left blank. The form also indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 14s medical record form titled ";POC/IDG Review" dated 11/14/2023, indicated the form was not signed by the medical doctor and chaplain. During a record review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised November 2021, indicated ";5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days. B. If no changes are needed, then that must be documented." During a record review of facilitys policy and procedure titled, ";The Plan of Care" revised November 2021, indicated ";The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days... This plan must be initiated at start of care..." During a record review of facilitys policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" revised November 2021, indicated ";The hospice interdisciplinary team/group members will include, at a minimum: A. Physician. B. Registered Nurse. C. Social Worker. D. Pastoral or another counselor. 3. The interdisciplinary group responsibilities include but are not limited to: A. Participate in the establishment of the plan of care for each patient admitted... B. Participate in the periodic review and updating of the plan of care for each patient receiving hospice services." During a record review of facilitys policy and procedure titled, ";Interdisciplinary Group Meeting" revised November 2021, indicated ";6. An interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. 5. 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."

Based on interview, and record review the Hospice failed to meet the Condition of Participation for IDG, Care Planning, Coordination of Services as follows: --- 1. The HA failed to ensure four of 14 sample patients (Patient 8, Patient 9, Patient 10, and Patient 11) plan of care was followed by not providing the scheduled visit frequency as stated in their individualized plan of care. This failure had the potential to result in patients not receiving all the necessary visits as schedule which may harm and cause patient to experience pain and anguish. (Refer to L543). 2. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse (RN), Medical Social Worker (MSW), Spiritual Counselor (SC), and Medical Director (MD) come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) included the scope and frequency for one of 14 sample patients (Patient 8) of patients visits necessary to meet their needs. This failure had the potential to result in patients not receiving the ordered services to provide comfort and support during their end of life. (Refer to L547). 3. The HA failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met to review and updated the comprehensive assessment at least every 15 days for eleven out of 14 sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 14). This deficient practice had potential for harm if patients are prevented from reaching their goals, due to IDG not addressing changes in the patient's condition. (Refer to L552). The cumulative effect of these systemic practices resulted in the failure of the Hospice to deliver statutorily mandated compliance with the Federal regulations for IDG, Care Planning, and Coordination of Services to ensure provision of hospice services are provided to patients certified for the hospice benefits.

Based on interview and record review the Hospice Agency (HA) failed to ensure the individualized written plans of care established by the IDG in collaboration with the physician were followed for four of 14 sample patients (Patient 8, Patient 9, Patient 10, and Patient 11). This failure had the potential to result in patients not receiving all the necessary services identified in the POC that affect the patients' health status and well-being. --- During an interview on 7/9/2024 at 1:50 p.m., with the Director of Patient Care Services (DPCS) stated, nurses have five days to document and submit their patient visit notes. DPCS stated nursing visit notes are needed for the interdisciplinary meetings. DPCS stated ";I need to know what is going on with the patient, so that I can address it to the rest of the team." 1. During a review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 6/7/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 8s medical record form titled ";Current Treatment/Medication/DME List", indicated ";Skilled nurse visits once a week +3 PRN (as needed) visits for changes in patient status/symptoms management." During a record review of Patient 8s Electronic Medical Record (EMR), medical record form titled ";History of Visit Notes" indicated the last nursing visit note was on 6/21/2024. The form also indicated the visit note dated 6/26/2024 had a red ";X" under status section. During a concurrent interview and record review on 7/11/2024 at 12:15 p.m. with the DPCS of Patient 8s medical record form titled ";History of Visit Notes" was reviewed, the DPCS stated the red colored ";X" under the status section of the form indicated the form was not signed or completed. DPCS stated there were at least two nurse visit notes in Patient 8s medical record. 2. During a review of Patient 9s medical record form titled ";Personal Information" indicated a start of care date of 5/27/2024, with a diagnosis of heart disease, unspecified. During a review of Patient 9s medical record form titled ";Current Treatment/Medication/DME List" indicated hospice aid once a week to assist with personal care and activities of daily living. During a record review of Patient 9s EMR, medical record form titled ";History of HA (home Aid) Visits" indicated the last home health aide visit note was entered on 5/22/2024. During a record review of Patient 9s EMR, medical record form titled ";History of Visit Notes" indicated the last nursing visit note was on 6/26/2024. During a concurrent interview and record review on 7/11/2024 at 1 p.m. with the DPCS of Patient 9s medical record, DPCS stated that according to the home aid notes Patient 9 last received home health aid services on 5/22/2024. DPCS stated Patient 9 declined home health aide services at some point, but there was nothing documented in her medical record. DPCS stated it was important to document patient visits to ensure the visit was done and what was done during the visit. 3. During a review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 7/16/2023, with a diagnosis of Alzheimers Disease (progressive memory loss). During a review of Patient 10s medical record form titled ";Current Treatment/Medication/DME List", indicated ";Spiritual care coordinator for spiritual assessment within 5 days of admission to identify spiritual needs/support to patient, family, and primary care giver." During a review of Patient 10s medical record form titled ";Spiritual Assessment" dated 5/7/2024, indicated form was left blank and it did not have a signature. During a record review of Patient 10s EMR, medical record form titled ";History of Spiritual Assessment" indicated the last visit note was on 3/8/2024. The form also indicated the visit note dated 5/7/2024 had a red ";X" under status section. During a concurrent interview and record review on 7/11/2024 at 1:10 p.m. with the DPCS of Patient 10s medical record form titled ";History of Spiritual Assessment" was reviewed, DPCS stated that there should be a recertification spiritual assessment conducted on 7/10/2024 for Patient 10. DPCS stated the last spiritual assessment for Patient 10 was completed on 3/8/2024. 4. During a review of Patient 11s medical record form titled ";Personal Information" indicated a start of care date of 4/26/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 11s medical record form titled ";Current Treatment/Medication/DME List", indicated ";skilled nurse visits one a week +3 PRN (as needed) visits for changes in patient status/symptoms management." During a record review of Patient 11s EMR, medical record form titled ";History of Visit Notes" indicated the last nursing visit note was on 5/29/2024. 5. During a review of Patient 12s medical record form titled ";Personal Information" indicated a start of care date of 5/1/2024, with a diagnosis of heart disease, unspecified. During a record review of Patient 12s EMR, medical record form titled ";History of Visit Notes" indicated the last nursing visit note was on 6/24/2024. During a record review of facilitys policy and procedure titled, ";Missed Visits" revised November 2021, indicated ";If a visit is missed for any reason, the clinician should attempt to reschedule it for the same week so that the physician ordered frequency is maintained and would not be considered a missed visit. If an aide visit is missed the aide will contact the case manager or clinical supervisor and the manager/supervisor will take the appropriate measures stated above. During a record review of facilitys policy and procedure titled, ";Clinical/Service Date Collection" revised November 2021, indicated ";Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. The clinical/service note will include: E. Signature or clinician/technician and his/her credentials."

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), Spiritual Counselor (SC), and Medical Director (MD) come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) included the scope and frequency care in the POC for one of 14 sample patients (Patient 8) of patients visits necessary to meet their needs. This failure had the potential to result in patients not receiving the ordered services to provide comfort and support during their end of life. --- During a review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 6/7/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 8s medical record form titled ";POC Summary", indicated ";Frequency of Visits: LVN: per week; RN: per 2-week +1 PRN visits..." During a review of Patient 8s medical record form titled ";POC/IDG Review" dated 6/7/2024, indicated Frequency of Visits: LVN: per week; RN: per 2-week +1 PRN visits..." The form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 8s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated Frequency of Visits: LVN: per week; RN: per 2-week +1 PRN visits..." The form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 8s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated Frequency of Visits: LVN: per week; RN: per 2-week +1 PRN visits..." The form also indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a concurrent interview and record review on 7/11/2024 at 12:15 p.m., with the Director of Patient Care Services (DPCS) of Patient 8s medical record, the DPCS stated Patient 8s POC was not complete because it was missing the frequency. DPCS stated it was important to have all the disciplines frequencies documented so that the care team are aware of everyones frequency. DPCS sated ";The patient should know their frequencies to know and when to expect when and who is coming to see them. To know their role and job." During a record review of facilitys policy and procedure titled, ";The Plan of Care" revised November 2021, indicated ";The written plan of care will contain, but will not be limited to, the following: M. Frequency/Amount/Duration and type of services." During a record review of facilitys policy and procedure titled, ";Scope of Services" revised November 2021, indicated ";4. Routine home visits will be provided according to the plan of care including scope and frequency." During a record review of facilitys policy and procedure titled, ";Patient Bill of Rights/Responsibilities" revised November 2021, indicated ";Q. Be informed of disciplines furnishing care and the frequency of visits."

Based on interview and record review, the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG - various hospice professionals (Registered Nurse, Medical Doctor, Medical Social Worker, Spiritual Counselor, all working together to create a comprehensive and customized hospice plan of care for each patient) met to review and update the comprehensive assessment at least every 15 days for eleven out of 14 sample selected patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, and Patient 14). This deficient practice had potential for harm if patients are prevented from reaching their goals, due to IDG not addressing changes in the patient's condition. --- During an interview on 7/9/2024, at 1:18 p.m., the Director of Patient Care Services (DPCS) stated the IDG members met every two weeks either in the office in person, or through a telephone video conference, for those who could not meet in person. The DPCS stated the Medical Social Worker (MSW) and Spiritual Counselor (SC) each documented their input of the meeting in the electronic medical record (EMR) and were expected to document the following day of the meeting day. The signature was expected to be entered by the 5th day following the meeting day. The DPCS stated he would transcribe the doctor and registered nurses input in the record. The registered nurse and doctor were expected to sign the document to validate their attendance and agreement with the notes entered by the DPCS. The DPCS stated the purpose of the IDG meeting was so everyone on the team has an update on what is going on with the patient, so that all the people involved in the care know why changes were made. During an interview on 7/9/2024 at 1:20 p.m., the DPCS stated the IDG members responsibilities include conducting comprehensive assessments, documenting their findings, and submitting them within 5 days. During an interview on 7/11/2024 at 12:15 p.m., the DPCS stated they have 5 days to document their IDG meetings. The DPCS stated IDG members signatures verify their attendance and their review of the discussions. The DPCS stated the HA does not have any verification the IDG members attended the patients IDG meetings. During an interview on 7/12/2024 at 2:15 p.m., the SC stated he has been working at the HA for a few months and was part of the IDG team. SC stated he has attended two IDG meetings since working at HA, which is receiving a phone call from an HA staff member to discuss the patients. SC stated he does not document in the HAs EMR (Electronic Medical Record) IDG section. SC stated, ";you would have to talk to the office on what and how they do their documentation." SC stated the last time he attended an HAs IDG meeting was two months ago because he has not received any notifications of IDGs. During an interview on 7/12/2024 at 2:30 p.m., the MSW stated she was an IDG member. MSW stated IDG meetings are held once a week and sometimes over ZOOM. MSW stated she was available via ZOOM or face time due to working somewhere else. MSW stated she logged into the HAs EMR while attending the IDG meetings to document and sign her portion. MSW was asked about the sample patients that do not have psychosocial assessments. MSW stated ";I am not doing a very good job, its my fault. Sometimes I forget to sign the IDG on the bottom." 1. A review of Patient 1s record titled, ";Personal Information", indicated a start of care date on 3/27/2024, with a diagnosis of hypertensive (high blood pressure) heart disease with heart failure (heart inability to pump blood effectively to the body). A record review of Patient 1s records titled ";POC/IDG", dated 5/13/2024, 5/27/2024, 6/24/2024, and 7/8/2024, did not have any signatures of the IDG members to validate their attendance and input in the meetings. The record dated 6/24/2024 did not have any nursing input documented and the record dated 7/8/2024 did not have any IDGs members input documented. 2. A review of Patient 2s record titled, ";Personal Information", indicated a start of care date of 3/27/2024, with a diagnosis of heart disease. A record review of Patient 2s records titled ";POC/IDG", dated 5/13/2024, 5/27/2024, 6/24/2024, and 7/8/2024, did not have any signatures of the IDG members to validate their attendance and input in the meetings. The record dated 6/24/2024 did not have any nursing input documented and the record dated 7/8/2024 did not have any IDGs members input documented. 3. A review of Patient 3s ";Personal Information" sheet indicated a start of care date on 11/17/2023, with a primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). During a concurrent interview and record review on 7/12/2024, at 12:50 p.m., the DPCS reviewed Patient 3s records. The DPCS stated the re-certification psychosocial assessment was supposed to be documented under the assessment tab, specifically psychosocial, in the electronic medical record (EMR). The DPCS stated the re-certification assessment was not done because the MSW either did not visit or visited the patient but did not document the visit. The DPCS stated a re-certification psychosocial assessment was important because that was the plan of care, you have to adhere to it, or you need to revise the plan of care. The risks of not doing an assessment were that the patients psychosocial needs will not be met. A record review of Patient 3s records titled ";POC/IDG", for dates 6/10/2024, 6/24/2024, and 7/8/2024, did not have any signatures of the IDG members to validate their attendance and input in the meetings. The record dated 6/24/2024 did not have any nursing input documented and the record dated 7/8/2024 did not have any IDGs members input documented. 4. A review of Patient 4s record titled, ";Personal Information", indicated a start of care on 4/25/2024, with a primary diagnosis of heart disease. A record review of Patient 4s records titled ";POC/IDG", for dates 6/10/2024, 6/24/2024, and 7/8/2024, did not have any signatures of the IDG members to validate their attendance and input in the meetings. The record dated 6/24/2024 did not have any nursing input documented and the record dated 7/8/2024 did not have any IDGs members input documented. 5. A review of Patient 5s record titled, ";Personal Information", indicated a start of care date on 3/28/2024, with a diagnosis of end stage heart failure (heart losing its ability to pump blood to the body effectively). During a record review of Patient 5s EMR, on 7/9/2024, at 3:09 p.m., the assessment tab ";spiritual" did not indicate a spiritual assessment. During a concurrent interview and record review on 7/12/2024, at 1:29 p.m., the DPCS reviewed Patient 5s records titled, ";Spiritual Assessment", dated 3/20/204 and 6/23/2024. The DPCS stated the spiritual assessment was in the medical records and was entered on 7/10/2024. The DPCS stated the SC did not document the assessment on time and did not know the reason why. The DPCS stated the spiritual assessment was needed to ensure the spiritual needs were identified and interventions done to meet those needs. The DPCS stated based on what was written in the assessments, the patient should have a plan of care that addresses her spiritual needs because he wrote the patient was sad. The note also said the patient wished to have community religious groups visit her. The DPCS then reviewed Patient 5s records titled, ";POD/IDG", dated 6/10/2024, 6/24/2024, and 7/8/2024. The DPCS stated the IDG meetings did not have her spiritual wishes addressed. A record review of Patient 5s records titled ";POC/IDG", for dates 6/10/2024, 6/24/2024, and 7/8/2024, did not have any signatures of the IDG members to validate their attendance and input in the meetings. The record dated 6/24/2024 did not have any nursing input documented and the record dated 7/8/2024 did not have any IDGs members input documented. 6. During a review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 6/7/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 8s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 8s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During an interview on 7/11/2024 at 12:15 p.m. with the DPCS, the DPCS stated Patient 8s IDG meeting dated 7/8/2024 was not completed. 7. During a review of Patient 9s medical record form titled ";Personal Information" indicated a start of care date of 5/27/2024, with a diagnosis of heart disease, unspecified. During a review of Patient 9s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 9s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing discussion section was left blank. The form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 9s medical record form titled ";POC/IDG Review" dated 6/10/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a concurrent interview and record review on 7/11/2024 at 1 p.m. with the DPCS of Patient 9s medical record, the DPCS stated Patient 9s IDG meetings dated 6/10/24, 6/24/2024, 7/8/2024, were not signed. DPCS stated ";How hard is it to click on the page." 8. During a review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 7/16/2023, with a diagnosis of Alzheimers Disease (progressive memory loss). During a review of Patient 10s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 10s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing discussion section was left blank. The form also indicated it was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 10s medical record form titled ";POC/IDG Review" dated 5/27/2024 and 6/10/2024, indicated the forms were not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a concurrent interview and record review on 7/12/2024 at 1:10 p.m. with the DPCS of Patient 10s medical record, the DPCS stated Patient 10s IDG meeting registered nurse discussion section dated 6/24/2024 was completed within the last 24 hours by him from the registered nurse notes completed on 6/16/2024. DPCS stated he did not indicate the documentation as a late entry. DPCS stated he need to document a late entry for quality assurance purposes and to keep track of timely submissions. DPCS stated Patient 10s IDG meeting dated 7/8/2024, he was the one who documented under the registered nurse and other/physician discussion sections. 9. During a review of Patient 11s medical record form titled ";Personal Information" indicated a start of care date of 4/26/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 11s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 11s medical record form titled ";POC/IDG Review" dated 6/10/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 11s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing documentation section was left blank. The form also indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a concurrent interview and record review on 7/12/2024 at 1:20 p.m. with the DPCS of Patient 11s medical record, the DPCS stated Patient 11s comprehensive assessments dated 6/10/2024, 6/24/2024, and 7/8/2024, were not completed or signed by the IDG members. 10. During a review of Patient 12s medical record form titled ";Personal Information" indicated a start of care date of 5/1/2024, with a diagnosis of heart disease, unspecified. During a review of Patient 12s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. The form also indicated it was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 12s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing discussion section was left blank. The form also indicated it was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a concurrent interview and record review on 7/12/2024 at 1:24 p.m. with the DPCS of Patient 12s medical record, DPCS stated Patient 12s IDG meeting dated 6/24/2024 did not have her problems, interventions, and goals listed because he forgot to click the button that imports that information on to the form. DPCS stated Patient 12s IDG meeting dated 7/8/2024, was completed within the last 24 hours. 11. During a review of Patient 14s medical record form titled ";Personal Information" indicated a start of care date of 11/14/2023 and end of care date of 6/19/2024, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque in the heart artery causing narrowing of artery without chest pain). During a review of Patient 14s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 14s medical record form titled ";POC/IDG Review" dated 6/10/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 14s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing discussion section was left blank. The form also indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 14s medical record form titled ";POC/IDG Review" dated 11/14/2023, indicated the form was not signed by the medical doctor and chaplain. During a record review of facilitys policy and procedure titled, ";Comprehensive Assessment" revised November 2021, indicated ";5. The comprehensive assessment is updated by the interdisciplinary group as frequently as the patients condition requires but at a minimum of every 15 days. B. If no changes are needed, then that must be documented." During a record review of facilitys policy and procedure titled, ";The Plan of Care" revised November 2021, indicated ";The plan of care will be based on the initial, comprehensive, and ongoing comprehensive assessments performed by members of the interdisciplinary group and will be reviewed on a regular basis but no less than every fifteen (15) days... This plan must be initiated at start of care..." During a record review of facilitys policy and procedure titled, ";Interdisciplinary Group Membership and Responsibilities" revised November 2021, indicated ";The hospice interdisciplinary team/group members will include, at a minimum: A. Physician. B. Registered Nurse. C. Social Worker. D. Pastoral or other counselor. 3. The interdisciplinary group responsibilities include but are not limited to: A. Participate in the establishment of the plan of care for each patient admitted... B. Participate in the periodic review and updating of the plan of care for each patient receiving hospice services." During a record review of facilitys policy and procedure titled, ";Interdisciplinary Group Meeting" revised November 2021, indicated ";6. An interdisciplinary group meeting plan of care update form will be used for update of the patient and family/caregiver and the attending physician. 5. 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.

Based on interview and record review the Hospice Agency (HA) failed to ensure one of 14 sampled patients (Patient 13) family had bereavement counseling after the patient's passing. This failure resulted in families/care givers did not receive the bereavement services after their family member passed away. --- During a review of Patient 13s medical record form titled ";Personal Information" indicated a start of care date of 3/26/2023, an end of care date of 10/5/2023, with a diagnosis of heart disease, unspecified. During a review of Patient 13s medical record form titled ";Discharge Summary" dated 10/5/2023, indicated the reason for discharge was death. The form also indicated it was not signed by the author. During a review of Patient 13s medical record form titled ";Report of Death and Disposal of Controlled Drugs" dated 10/5/2023, indicated it was not signed by the author. During a review of Patient 13s medical record form titled ";Post Death Bereavement Support" undated, indicated the form was left blank. The form also indicated an end of care date of 10/5/2023. The form also indicated bereavement letters were overdue for Month 1 (11/5/2023), Month 3 (1/5/2024), Month 6 (4/5/2024), and Month 9 (7/5/2024). During a review of Patient 13s medical record form titled ";Post Death Bereavement Assessment" dated 10/6/2023, indicated form was left blank. During a concurrent interview and record review on 7/12/2024 at 1:48 p.m. with the Director of Patient Care Services (DPCS) of Patient 13s medical record, the DPCS stated he completed Patient 13s discharge summary on 10/5/2023, but signed it on 7/12/2024 at 7:42 a.m. The DPCS stated he is not aware of who completed the medical record form titled ";Report of Death and Disposal of Controlled Drugs" because it was not signed. During an interview on 7/12/2024 at 2:15 p.m. with the Spiritual Counselor (SC), the SC stated his role was to provide spiritual and bereavement support to hospice patients. SC stated his documentation should be completed within 5 days after a patients visit. During a record review of facilitys policy and procedure titled, ";Bereavement Assessment" revised November 2021, indicated ";(HA) will provide bereavement services for up to one (1) year after the patients death to surviving family/caregiver members. 3. After the death occurs, the hospice social worker or Bereavement Coordinator will complete the bereavement follow-up assessment. 4. The Bereavement Coordinator will develop a plan for intervention, based on the findings of the bereavement follow-up assessment." During a record review of facilitys policy and procedure titled, ";Clinical/Service Date Collection" revised November 2021, indicated ";Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday."

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Medical Director was met as evidenced by: --- 1. The hospice agency failed to ensure, the medical director and/or physician designee conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications for six of 14 sample patients (Patient 2, Patient 4, Patient 5, Patient 8, Patient 10 , and Patient 12) to support diagnosis of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. The agency failed to: Ensure there was a physicians signature and documentation of clinical information that included patients objective medical findings (written supporting documentation about the illness) necessary for initial certification of hospice are and services. Also written certification that the patient's life expectancy is 6 months or less if the illness runs its normal course. These deficient practices resulted in the hospice medical director and/or the hospice attending physicians certified the patients for hospice care without documentation of clinical evidence to support the terminal illness diagnoses and could result to lack and inappropriate care provided to the patients. (Refer to L 667). 2. The hospice agency failed to ensure medical director and/or physician designee conducted a review and verify the patients clinical information to determine patient needs of recertification of terminal illness for continued hospice care and services four of 14 sample patients (Patient 2, Patient 4, Patient 5, and Patient 8). (Refer to L 668). The cumulative effect of this systemic practice resulted in the failure of the hospice to deliver statutory mandated compliance with Federal regulation for Medical Director services to ensure highest quality of patient care are provided to the patients certified to receive hospice services.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure, the medical director and/or physician designee: -Conducted an accurate assessment, review, and verify the patient clinical information, necessary for initial certifications for six of 14 sample patients (Patient 2, Patient 4, Patient 5, Patient 8, Patient 10 , and Patient 12) to support diagnoses of the patients terminal illnesses and to qualify for hospice (health care that focuses on the palliation of a terminally ill patients pain and symptoms and attending to their emotional and spiritual needs at the end of life) care. -Obtained and reviewed the patients documented clinical information necessary for initial certification for hospice care and services that included patient's history and physical, laboratory and imaging data, and biopsy results. These deficient practices resulted in the hospice medical director and/or the hospice attending physician certifying these patients to receive the hospice benefits without clinical evidence to support the terminal illness diagnoses including written certification that the patient's life expectancy is 6 months or less if the illness runs its normal course. These deficient practices resulted in the hospice medical director and/or the hospice attending physicians certifying these patients for hospice care without clinical evidence to support the terminal illness diagnoses that could affect the quality of care provided to certified patients receiving the benefits. --- During an interview on 7/9/2024, at 1:42 p.m., the Director of Patient Care Services (DPCS) stated he transcribed the doctors (Medical Director 1- MD 1) certification that was emailed to him by the doctor, into the Electronic Medical Record (EMR). The DPCS stated the doctor would review the notes, edit if needed, and signed them to show approval with what was entered by the DPCS. During an interview on 7/12/2024, at 11:06 a.m., MD 1 stated the process of certification was as follows: The HA sends her the KPS (Karnofsky Performance Status, a scale used to measure a patients ability to perform activities of daily living) medication list, and medical documents (if the patient has been in the hospital). The nurse visits the patient and the nurse face time (a video-telephone method of communication) MD 1. The nurse gives MD 1 the assessment (they text MD 1 the information. If case is complicated call MD 1 directly). The nurse sends MD 1 two paragraphs of nursing assessment with info on KPS, activity levels, medication list. Then the nurse will go to the visit and face time MD 1. MD 1 introduces herself, tells them she will be covering their medical needs. The nurse assesses the information first, sends MD 1 the information, then MD 1 requests for the nurse to go back and face time the visit. The visit could be on the same day or the next day. If patient is available, and if MD 1 is available, it could be the same day. During an interview on 7/12/2024 at 11:12 a.m., MD 1 stated the process for documenting the certification into hospice care was as follows: MD 1 tells them (nurses) the medical assessment, what to do, what to write. The nurses write it, its a matter of typing it. MD 1 verifies the information, changes it if needed, and then the note is signed by MD 1. MD 1 stated, ";I tell them what to type in hospice MD (electronic medical record). During an interview on 7/12/2024, at 11:20 a.m., MD 1 stated she did not use the LCD (Local Coverage Determination, a tool use to determine if patient has the hospice admission criteria based on the disease) to admit patients into hospice care. MD 1 stated ";I just follow the progression of the disease. I look at the KPS. As much as I know, it is not a necessity. It is a guideline, not the law". During an interview on 7/12/2024 at 11:43 p.m., with MD1, MD1 stated she does not send, fax, or emails patients written report into the HA. MD1 stated she dictates her assessment/findings to the HA staff via a phone call. MD1 stated that if the regulations require for her to document her assessment/findings herself, she will follow it from now on. MD1 was informed that advice is not given/provided. 1. A review of Patient 2s record titled, ";Personal Information", indicated a start of care date of 3/27/2024, with a diagnosis of heart disease. During an observation of the home visit on 7/10/2024, at 9:59 a.m., with the Director of Patient Care Services (DPCS), a white 4 door sedan was pulling out of the residence driveway. A Hispanic female, with short hair, wearing sunglasses was at the drivers seat, with the seatbelt on. There were no other passengers in the car. The driver was not wearing and/or using any medical device. There was no observed use of oxygen equipment around her nares. Surveyor greeted passenger and female waved back at surveyor. Female driver did not stop the car. The windows were closed, and the female driver drove off. During a concurrent observation and interview at the home visit on 7/10/2024, at 10:05 a.m., with the DPCS, a young female (relative-REL) was standing in the front lawn of the home. The REL stated she was the granddaughter of Patient 2. The REL stated the female who had driven off the property was her grandmother. The REL stated, ";yes, she drives". During an interview on 7/10/2024, at 10:07 a.m., Patient 1 (Patient 2s husband) stated him and Patient 2 were getting ready to fly out of the state because Patient 2s mother was sick. Patient 1 stated Patient 2 did not have any heart problems, was not seeing a cardiologist (a doctor who specializes in the heart), and only saw a primary care doctor. Patient 1 stated Patient 2s medical problems were diabetes. During an interview on 7/12/2024, at 11:41 a.m., MD 1 stated patients who were classified as NYHA IV (New York Heart Association classification of heart failure, level 4 is the highest level of heart failure. Patient has symptoms at rest. If any physical activity is undertaken, physical discomfort increased) meant they were in the last stages of congestive heart failure (CHF) and minimum activity is tolerated. MD 1 stated patients with NYHA IV were able to go to doctors appointments with transportation. MD 1 stated ";NYHA IV doesnt mean anything of what they can and cant do". MD 1 stated a patient who is classified as NYHA IV can drive a car. It depends on the co-morbidities (other illnesses that affect health). MD 1 stated if a patient gets treatment for CHF, it is medically possible that a patient can improve, and their end stage hear disease can improve. A review of Patient 2s records titled, ";Comprehensive Nursing Assessment", dated 3/27/2024, indicated Patient 2 was classified with NYHA IV, was optimally treated for heart disease with diuretics and vasodilators. Further review of the record indicated Patient 2s blood pressure was 120/72 (levels fall within the established normal parameters, based on standards of care) and the patient was experiencing mild shortness of breath with mild exertion (activity). The oxygen saturation readings (measures the percentage of oxygen in the body) were 98% (normal level based on standards of care) while breathing the oxygen in the air (room air). A review of Patient 2s undated records titled, ";Current Treatment/Medication/DME List", did not have any medications listed for high blood pressure. During a concurrent interview and record review on 7/12/2024, at 12:01 p.m., MD 1 reviewed Patient 2s record titled, ";Physicians Certification for Hospice Benefit (CTI)", for certification dates 3/27/2024 to 6/24/2024. The record indicated, ";Certifying Physician Narrative...Patient has unstable blood pressure...Patient has SOB (shortness of breath) on moderate exertion...NYHA IV". MD 1 stated her decision on certifying Patient 2 for hospice care was based on her assessment, knowledge, and patient reports. MD 1 stated, ";the patients will say anything to get what they want." The unstable blood pressure was based on the nurses report. MD 1 stated, blood pressure 120/70 was not unstable, and Patient 2 was not on any heart medications. When asked how MD 1 determined Patient 2s blood pressure was unstable, MD 1 stated unstable meant the blood pressure goes up and down, based on the history of the patient as reported by the nurse. Further review of the record indicated MD 1 had signed the document under the attestation section of the document indicating ";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 7/12/2024, at 12:43 p.m., the DPCS reviewed Patient 2s record titled, ";Audit Log", dated 4/1/2024 to 7/12/2024. The record indicated the DPCS had entered notes in the physician narrative of the CTI for the certification period beginning on 3/27/2024, on 4/5/2024. Further review of the record indicated MD 1 signed the document on 5/13/2024. The DPCS stated he had entered the information into the EMR late. The DPCS stated signed the CTI late and did not know why. 2. A review of Patient 4s record titled, ";Personal Information", indicated a start of care on 4/25/2024, with a primary diagnosis of heart disease. A review of Patient 4s medical records on 7/9/2024, at 2:33 p.m., indicated the CTI for certification period 4/25/2024 to 7/23/2024 was not signed. During a concurrent interview and record review on 7/12/2024, at 12:24 p.m., the DPCS reviewed Patient 4s medical records titled, ";CTI", for certification period 4/25/2024 to 7/23/2024. The DPCS stated the CTI was completed. During a concurrent interview and record review on 7/12/2024, at 12:25 p.m., the DPCS reviewed Patient 4s medical records titled, ";Audit Log", dated 5/6/2024 to 7/12/2024. The record indicated the DPCS had entered notes in the physician narrative of the CTI for certification period beginning on 4/25/2025, on 7/10/2024. Further review of the record indicated MD 1 signed the document on 7/10/2024. When asked why the patient was admitted into hospice care without being certified, the DPCS stated, ";Because team members didnt do their job when it comes to their responsibilities. Patient was admitted incorrectly the wrong way". 3. A review of Patient 5s record titled, ";Personal Information", indicated a start of care date on 3/28/2024, with a diagnosis of end stage heart failure (heart losing its ability to pump blood to the body effectively). A record review of Patient 5s record titled, ";CTI", for certification period 3/28/2024 to 6/25/2024 indicated MD 1s signature under the attestation that read ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/pr examination of the patient." A record review of Patient 5s record titled, ";Audit Log", dated 3/28/2024 to 5/17/2024, indicated the CTI for certification period beginning on 3/28/2024 was entered by the DPCS on 5/17/2024. The date of when MD 1 signed was unable to be determined because an image was placed over the date. Able to read ";6/", month of June is determined based on chronological order of document. 4. During a joint home on 7/10/2024 at 9:45 a.m. visit with Registered Nurse 2 (RN2) to Patient 8s residence, man noted coming out of the home to pick up a fast food delivery. Patient 8s residence fence was locked, RN2 called Patient 8 and asked him to come unlock the gate. Patient 8 met us outside his home, he was awake, alert oriented, ambulatory, and was the same man who picked up the fast food delivered earlier. Patient 8 requested to conduct the home visit outside because he did not feel comfortable letting us into his home due to his ";mental issues". Patient 8 stated he was going to take public transportation by himself, to go see his doctor later in the day. Patient 8 refused to provide his doctors name, phone number, or address. Patient 8 stated he was not told he had six months or less to live by a physician. During a concurrent interview and record review on 7/11/2024 at 12:15 p.m. with the Director of Patient Care Services (DPCS) of Patient 8s medical record form titled ";Physician Certification for Hospice Services" dated from 6/7/2024 to 8/5/2024, the DPCS stated patient referrals are not required but are important to know that the patient is deemed by their doctor for hospice services. DPCS stated he dictated Patient 8s CTI from Medical Doctor 1 (MD1) via a phone call. DPCS stated he uses a template and alters it to the specific patient. DPCS stated MD1 signed Patient 8s CTI sometime from yesterday (7/10/2024) to today (7/11/2024). DPCS stated that a patient cannot be admitted without an admission order. DPCS stated Patient 8 did not have admissions orders in his medical record. During a concurrent interview and record review on 7/12/2024 at 11:40 a.m. with the DPCS of Patient 8s medical record, DPCS stated Patient 8 did not have documented face to face entry from MD1 in his medical record. DPCS stated he dictates MD1s findings into patients CTI via a phone call. During a review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 6/7/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 8s medical record form titled ";Current Treatment/Medication/DME List" did not indicate an order for Patient 8s admission or diagnosis. The form indicated ";Admit patient to (HA) for the 2nd benefit period from ******* under routine care with a primary diagnosis of *****." During a review of Patient 8s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #13: Re-Certification Statement for Next 60-day period" verbal authorization date 6/7/2024, indicated Medical Doctor 1s (MD1) name was listed as the referring physician attesting ";It is in my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course." The form also indicated it was not signed by MD1 or indicated if she wanted to follow up with the patient or not as their primary physician. During a review of Patient 8s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #13: Re-Certification Statement for Next 60-day period" effective date of certification from 6/7/2024 to 8/5/2024, indicated Medical Doctor 1s (MD1) name was listed as the physician attesting ";I certify that patients condition is terminal and may lead to death in six months or less, if the disease continues to runs its normal course." The form also indicated it was not signed by MD1. During a review of Patient 8s medical record form titled ";Comprehensive Nursing Assessment" dated 6/7/2024, indicated Patient 8 needs moderate assistance with ambulation, toileting, transfer, dressing, feeding, and bathing. The form also indicated, a score of KPS 50 and PPS 50. Irregular apical, pedal, radial, and femoral pulses. Respiratory exertion level with mild exertion. Lastly, the form indicated Patient 8 is dependent on walker or cane. 5. During a concurrent interview and record review on 7/12/2024 at 11:40 a.m. with the DPCS of Patient 10s medical record, DPCS stated Patient 10 did not have documented face to face entry from MD1 in his medical record. DPCS stated he dictates MD1s findings into patients CTI via a phone call. During a review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 7/16/2023, with a diagnosis of Alzheimers Disease (progressive memory loss). During a review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #12: Re-Certification Statement for Next 60-day period" effective date of certification from 7/10/2024 to 9/7/2024, indicated Medical Doctor 1s (MD1) name was listed as the physician attesting ";I certify that patients condition is terminal and may lead to death in six months or less, if the disease continues to runs its normal course." The form also indicated it was not signed by MD1. 6. During a concurrent interview and record review on 7/12/2024 at 1:24 p.m. with the DPCS of Patient 12s medical record form titled ";Physician Certification for Hospice Services" dated 5/1/2024 to 7/29/2024, DPCS stated Patient 12s CTI certifies the patients diagnosis is terminal and will expire within six months or less. DPCS stated he was unable to locate Patient 12s hospice referral or communication with Patient 12s doctor in her medical record. DPCS stated Patient 12 was not certified by a physician for hospice services on 5/1/2024. DPCS stated Patient 12s CTI dated 5/1/2024 was signed by the physician within the last 24 hours. DPCS stated Patient 12 did not receive the ";best" evaluation for hospice care. DPCS stated he did not know if Patient 12 qualified for hospice services based on the medical record. During a concurrent interview and record review on 7/12/2024 at 1:24 p.m. with the DPCS of Patient 12s medical record form titled ";LCD Hospice Eligibility Determination" dated 5/1/2024, DPCS stated ";We dont know if this patient qualifies for hospice services, based on her EMR." During a review of Patient 12s medical record form titled ";Personal Information" indicated a start of care date of 5/1/2024, with a diagnosis of heart disease, unspecified. During a review of Patient 12s medical record form titled ";LCD Hospice eligibility Determination" dated 5/1/2024, indicated ";heart disease (1 and 2 must be met)". Section 1 indicated Patient 12 had decline surgical procedures. Section 2 indicated Patient 12 met the criteria for NYHA (New York Heart Association) Class IV (patients with cardiac disease resulting in inability to carry on any physical activity without discomfort) level. During a review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefit – Statement for first 90-day period" verbal authorization date 5/1/2024, indicated Medical Doctor 2s (MD2) name was listed as the referring physician attesting ";It is in my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course." The form also indicated it was not signed by MD2 or indicated if she wanted to follow up with the patient or not as their primary physician. During a review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" effective date of certification from 5/1/2024 to 7/29/2024, indicated Medical Doctor 1s (MD1) name was listed as the physician attesting ";I certify that patients condition is terminal and may lead to death in six months or less, if the disease continues to runs its normal course." The form also indicated it was not signed by MD1. During a review of Patient 12s medical record form titled ";Comprehensive Nursing Assessment" dated 5/1/2024, indicated Patient 12 a score of KPS 50 and PPS 50. During a record review of facilitys policy and procedure titled, ";Admission Criteria and Process" revised November 2021, indicated ";(HA) will admit any patient with a life-limiting illness that meets the admission criteria. Patients will be accepted for care based on need for hospice services. The patients life-limiting illnesses and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determination (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." During a record review of facilitys policy and procedure titled, ";Certification of Terminal Illness" revised November 2021, indicated ";Patient who elect the hospice Medicate or Medicaid benefit will be certified as terminally ill, with a prognosis of six (6) months or less life expectancy if the disease runs its normal course by the attending physician and the hospice Medical Director. 1. At the time of admission to hospice, the hospice Medical Director... will complete a certification narrative that reflects the patients individual circumstances based on: his/her review of the patients medical record or if applicable examination of the patient. 3. 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." During a record review of facilitys policy and procedure titled, ";Clinical/Service Date Collection" revised November 2021, indicated ";Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. The clinical/service note will include E. Signature or clinician/technician and his/her credentials.

Based on observation, interview and record review the Hospice Agency (HA) failed to ensure the medical director and/or physician designee conducted reviews and verified the patients' clinical information to determine patients' needs of recertification of terminal illness for continued hospice care and services for four of 14 sample patients (Patient 1, Patient 2, Patient 5, and Patient 8). This deficient practice resulted in the medical director and/or designee recertifying these patients who did not need hospice care and service management for terminal illness. --- During an interview on 7/9/2024, at 1:42 p.m., the Director of Patient Care Services (DPCS) stated he transcribed the doctors (Medical Director 1- MD 1) certification that was emailed to him by the doctor, into the Electronic Medical Record (EMR). The DPCS stated the doctor would review the notes, edit if needed, and signed them to show approval with what was entered by the DPCS. The DPCS stated a face-to-face examination by MD 1 was required by the 3rd recertification period. During an interview on 7/12/2024 at 11:12 a.m., MD 1 stated the process for documenting the recertification into hospice care was as follows: MD 1 tells them (nurses) the medical assessment, what to do, what to write. The nurses write it, its a matter of typing it. MD 1 verifies the information, change it if needed, and then the note is signed by MD 1. MD 1 stated, ";I tell them what to type in hospice MD (electronic medical record). 1. A review of Patient 1s record titled, ";Personal Information", indicated a start of care date of 3/27/2024, with a diagnosis of hypertensive (high blood pressure) heart disease with heart failure. During an observation of the home visit on 7/10/2024, at 10:05 a.m., with the Director of Patient Care Services (DPCS), a young female (relative-REL) was standing in the front lawn of the home. The REL stated she was the granddaughter of Patient 1. The REL stated Patient 1 was not home and he was at the doctors appointment. The REL stated Patient 1 might have forgotten about todays visit and stated would call Patient 1. During an interview on 7/10/2024, at 10:07 a.m., with the DPCS, Patient 1 stated he was at his primary care doctors appointment. Patient 1 stated he and his wife, Patient 2, were getting ready to travel out of the state due to Patient 2s mother being sick. Patient 1 stated he was referred to the hospice program by a friend. Patient 1 stated he understood the program was to help older people like himself, with medicine. Patient 1 stated he was told it was for people who were dying but told ";them" (HA) he was not dying. When asked if Patient 1 had a terminal illness, he stated, ";no". When asked if a doctor had told him that his medical condition had a life expectancy of 6 months or less, Patient 1 stated, ";no". Patient 1 stated he was seeing a cardiologist (a doctor who specializes in the heart) and the doctor had said his heart was good. Patient 1 stated if at any point his heart was not well, he would do an operation to make it better. Patient 1 stated he was not short of breath, and he did not require the use of oxygen. During an interview on 7/10/2024, at 10:15 a.m., the DPCS stated Patient 1 was not allowed to see a cardiologist and primary care doctor while on hospice care. The DPCS stated the HA did not know he was seeing a cardiologist and primary care doctor. During a concurrent interview and record review on 7/12/2024, at 11:41 a.m., MD 1, reviewed Patient 1s record titled, ";Physician Certification for Hospice Benefit" (CTI) for recertification period (4th certification) 5/26/2024 to 7/24/2024. MD 1 stated this was her note and she had not written it. MD 1 stated she told the HA nurse to type in the computer for her. MD 1 stated she told them verbally what to write and did not send progress notes by email to the HA. When the HA put in the note, MD 1 checked it and signed it. A record review of Patient 1s record titled, ";CTI", for recertification period (4th certification) 5/26/2024 to 7/24/2024, indicated under physician narrative, ";...NYHA IV. Significant decline in health condition observed during the last period." Further review of the record indicated MD 1 had signed the document under the attestation section of the document indicating ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." 2. A review of Patient 2s record titled, ";Personal Information", indicated a start of care date of 3/27/2024, with a diagnosis of heart disease. A record review on 7/9/2024, at 12:47 p.m., of Patient 2s record titled, ";CTI", for re-certification period of 6/25/2024 to 8/23/2024, indicated notes were entered under section ";Physician Narrative" and ";Certifying Physician Narrative". Continued review of the record did not have a signature of the doctor. During an observation of the home visit on 7/10/2024, at 9:59 a.m., with the DPCS, a white 4 door sedan was pulling out of the residence driveway. A Hispanic female, with short hair, wearing sunglasses was at the drivers seat, with the seatbelt on. There were no other passengers in the car. The driver was not wearing and/or using any medical device. There was no observed use of oxygen equipment around her nares. Surveyor greeted passenger and female waved back at surveyor. Female driver did not stop the car. The windows were closed, and the female driver drove off. During a concurrent observation and interview at the home visit on 7/10/2024, at 10:05 a.m., with the DPCS, a young female (relative-REL) was standing in the front lawn of the home. The REL stated she was the granddaughter of Patient 2. The REL stated the female who had driven off the property was her grandmother. The REL stated, ";yes, she drives". During an interview on 7/10/2024, at 10:07 a.m., Patient 1 (Patient 2s husband) stated him and Patient 2 were getting ready to fly out of the state because Patient 2s mother was sick. Patient 1 stated Patient 2 did not have any heart problems, was not seeing a cardiologist (a doctor who specializes in the heart), and only saw a primary care doctor. Patient 1 stated Patient 2s medical problems were diabetes. During an interview on 7/10/2024, at 10:15 a.m., the DPCS stated Patient 2 was not using oxygen while driving. When asked if a patient with NYHA IV (New York Heart Association classification of heart failure, level 4 is the highest level of heart failure. Patient has symptoms at rest. If any physical activity is undertaken, physical discomfort increased) classification is capable of driving, the DPCS stated, ";he imagined a patient with NYHA IV laying on the couch who cant do anything. Even sitting up causes short of breath. Stated NYHA IV definitely cannot drive." During an interview on 7/12/2024, at 11:41 a.m., MD 1 stated patients who were classified as NYHA IV meant they were in the last stages of congestive heart failure (CHF) and minimum activity is tolerated. MD 1 stated patients with NYHA IV were able to go to doctors appointments with transportation. MD 1 stated ";NYHA IV doesnt mean anything of what they can and cant do". MD 1 stated a patient who is classified as NYHA IV can drive a car. It depends on the co-morbidities (other illnesses that affect health). MD 1 stated if a patient gets treatment for CHF, it is medically possible that a patient can improve and their end stage hear disease can improve. During a concurrent interview and record review on 7/12/2024, at 11:54 a.m., MD 1 reviewed Patient 2s record titled, ";CTI", for the 3rd re-certification period of 6/25/2024 to 8/23/2024. The record indicated, ";...Patient continue to have activity intolerance, increasing weakness, easily fatigues and frequent episodes of SOB, unable to care for self, requires maximum assistance, fair to poor appetite." When MD 1 was asked how the information was obtained, MD 1 stated, from the patient history of shortness of breath, chest pain, heart disease. MD 1 stated this was not a good admission. MD 1 stated, ";sometimes patients exaggerate to get more treatment." MD 1 reviewed Patient 2s record titled, ";Re-Cert Assessment", dated 5/22/2024. The record indicated Patient 2s blood pressure was 119/69 (levels fall within the established normal parameters, based on standards of care). MD 1 stated Patent 2s blood pressure was not hypertensive (high). MD 1 stated she signed the CTI yesterday, when the HA called her to tell her the note was entered. MD 1 stated she was supposed to complete the CTI two weeks prior of when the next recertification was due. During a concurrent interview and record review on 7/12/2024, at 12:43 p.m., the DPCS reviewed Patient 2s record titled, ";Audit Log", dated 4/1/2024 to 7/12/2024. The record indicated MD 1 signed the CTI for re-certification beginning 6/25/2024, on 7/9/2024. The DPCS stated the signature was late and the patient continued in the hospice service without being recertified by MD 1. When asked why the recertification was late, the DPCS stated he did not know why the HA was late on the documentation. The doctor is the one who is responsible in certifying the patient for hospice. Continued review of the record indicated the DPCS entered the physician narrative in the EMR on 6/18/2024. 3. A review of Patient 5s record titled, ";Personal Information", indicated a start of care date on 3/28/2024, with a diagnosis of end stage heart failure (heart losing its ability to pump blood to the body effectively). A record review on 7/9/2024, at 3:21 p.m., of Patient 5s record titled, ";CTI", for re-certification period of 6/26/2024 to 9/23/2024, indicated notes were entered under section ";Physician Narrative" and ";Certifying Physician Narrative". Continued review of the record did not have a signature of the doctor. During a concurrent interview and record review on 7/12/2024, at 12:28 p.m., the DPCS reviewed Patient 5s record titled, ";Audit Log", dated 5/16/2024 to 7/12/2024. The record indicated the DPCS entered the physician narrative for recertification beginning on 6/26/2024, in the EMR on 6/18/2024. The DPCS stated MD 1 signed the document on 7/9/2024. The DPCS stated the doctor signed the document late and the patient continued hospice care without a doctors recertification. 4. During a joint home on 7/10/2024 at 9:45 a.m. visit with Registered Nurse 2 (RN2) to Patient 8s residence, man noted coming out of the home to pick up a fast food delivery. Patient 8s residence fence was locked, RN2 called Patient 8 and asked him to come unlock the gate. Patient 8 met us outside his home, he was awake, alert oriented, ambulatory, and was the same man who picked up the fast food delivered earlier. Patient 8 requested to conduct the home visit outside because he did not feel comfortable letting us into his home due to his ";mental issues". Patient 8 stated he was going to take public transportation by himself, to go see his doctor later in the day. Patient 8 refused to provide his doctors name, phone number, or address. Patient 8 stated he was not told he had six months or less to live by a physician. Patient 8 stated he was discharged from hospice care due to being hospitalized for 10 days in May 2024 but resumed care in June 2024. During a concurrent interview and record review on 7/11/2024 at 12:15 p.m. with the Director of Patient Care Services (DPCS) of Patient 8s medical record, DPCS stated patient referrals are not required but are important to know that the patient is deemed by their doctor for hospice services. During a concurrent interview and record review on 7/12/2024 at 11:40 a.m. with the DPCS of Patient 8s medical record, DPCS stated Patient 8 did not have documented face to face entry from MD1 in his medical record. DPCS stated he dictates MD1s findings into patients CTI via a phone call. During a review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 10/15/2023 and end of care date of 5/26/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 8s Electronic Medical Record (EMR), the EMR indicated under section ";Document/Images – Referral" there was a prescription from Medical Doctor 2 (MD2) which stated ";Chronic Obstructive Pulmonary Disease, unspecified". During a review of Patient 8s medical record form titled ";Physicians Certification for Hospice Benefits" dated 10/15/2023 to 12/13/2023, indicated MD2s name was listed as the referring physician attesting ";It is in my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course." The form also indicated it was not signed by MD2 or indicated if he wanted to follow up with the patient or not as their primary physician. During a record review of facilitys policy and procedure titled, ";Admission Criteria and Process" revised November 2021, indicated Eligibility criteria will be continually reviewed by the interdisciplinary team to ensure appropriateness of hospice care." During a record review of facilitys policy and procedure titled, ";Certification of Terminal Illness" revised November 2021, indicated ";A subsequent recertification, at the beginning of each new benefit period... At recertification, the hospice Medical Director must compose and sign the narrative based on a review of the patients medical record or... examination of the patient." During a record review of facilitys policy and procedure titled, ";Clinical/Service Date Collection" revised November 2021, indicated ";Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. The clinical/service note will include E. Signature or clinician/technician and his/her credentials.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation on Clinical Records was met as follows: --- 1. The HA failed to ensure 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 twelve of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure resulted in an unauthorized and inaccurate patient information or assessment entered in the patients clinical record that could affect the patients quality of care and well-being. (Refer to L679). 2. The HA failed to notify the attending physician of three of 14 sampled patients (Patient 8, Patient 13, and Patient 14) regarding their discharge. This failure resulted in the patients attending physician does not know about Patient 8 and Patient 14s discharge due to extended prognosis and Patient 13s discharge due to death, which had the potential to cause confusion. (Refer to L683). 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 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 twelve of 14 sampled patients (Patient 1, Patient 2, Patient 3, Patient 4, Patient 5, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure resulted in an unauthorized and inaccurate patient information or assessment entered in the patients clinical record that could affect the patients quality of care and well-being. --- During an interview on 7/9/2024, at 1:18 p.m., the Director of Patient Care Services (DPCS) stated the Medical Social Worker (MSW) and Spiritual Counselor (SC) each documented their input of the meeting in the electronic medical record (EMR) and were expected to document the following day of the meeting day. The signature was expected to be entered by the 5th day following the meeting day. The DPCS stated he would transcribe the doctor and registered nurses input in the record. The registered nurse and doctor were expected to sign the document to validate their attendance and agreement with the notes entered by the DPCS. During an interview on 7/9/2024, at 1:42 p.m., the DPCS stated he transcribed the doctors (Medical Director 1- MD 1) certification that was emailed to him by the doctor, into the Electronic Medical Record (EMR). The DPCS stated the doctor would review the notes, edit if needed, and signed them to show approval with what was entered by the DPCS. During an interview on 7/12/2024 at 11:12 a.m., MD 1 stated the process for documenting the recertification into hospice care was as follows: MD 1 tells them (nurses) the medical assessment, what to do, what to write. The nurses write it, its a matter of typing it. MD 1 verifies the information, change it if needed, and then the note is signed by MD 1. MD 1 stated, ";I tell them what to type in hospice MD (electronic medical record). 1. A review of Patient 1s record titled, ";Personal Information", indicated a start of care date on 3/27/2024, with a diagnosis of hypertensive (high blood pressure) heart disease with heart failure (heart inability to pump blood effectively to the body). A record review of Patient 1s records titled ";POC/IDG", dated 5/13/2024, indicated documentation for sections ";nursing, spiritual, psychosocial". The document did not indicate the author of the entries. A record review of Patient 1s records titled ";POC/IDG", dated 5/27/2024, indicated documentation for sections ";nursing, spiritual, psychosocial". The document did not indicate the author of the entries. A record review of Patient 1s records titled ";POC/IDG", dated 6/10/2024, indicated documentation for sections ";nursing, spiritual, psychosocial". The document did not indicate the author of the entries. A record review of Patient 1s records titled ";POC/IDG", dated 6/24/2024, indicated documentation for sections ";spiritual, psychosocial". The document did not indicate the author of the entries. During a concurrent interview and record review on 7/12/2024, at 11:41 a.m., the Medical Doctor (MD 1), reviewed Patient 1s record titled, ";Physician Certification for Hospice Benefit" (CTI) for recertification period (4th certification) 5/26/2024 to 7/24/2024. MD 1 stated this was her note and she had not written it. MD 1 stated she told the HA nurse to type in the computer for her. MD 1 stated she told them verbally what to write and did not send progress notes by email to the HA. When the HA put in the note, MD 1 checked it and signed it. A record review of Patient 1s record titled, ";CTI", for recertification period (4th certification) 5/26/2024 to 7/24/2024, indicated MD 1 had signed the document under the attestation section of the document indicating ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." 2. A review of Patient 2s record titled, ";Personal Information", indicated a start of care date of 3/27/2024, with a diagnosis of heart disease. A record review of Patient 2s records titled ";POC/IDG", dated 5/13/2024, indicated documentation for sections ";nursing, spiritual, psychosocial". The document did not indicate the author of the entries. A record review of Patient 2s records titled ";POC/IDG", dated 5/27/2024, indicated documentation for sections ";nursing, spiritual, psychosocial". The document did not indicate the author of the entries. A record review of Patient 2s records titled ";POC/IDG", dated 6/10/2024, indicated documentation for sections ";nursing, spiritual, psychosocial". The document did not indicate the author of the entries. A record review of Patient 2s records titled ";POC/IDG", dated 6/24/2024, indicated documentation for sections ";spiritual, psychosocial". The document did not indicate the author of the entries. During a concurrent interview and record review on 7/12/2024, at 12:01 p.m., MD 1 reviewed Patient 2s record titled, ";Physicians Certification for Hospice Benefit (CTI)", for certification dates 3/27/2024 to 6/24/2024.The record indicated MD 1 had signed the document under the attestation section of the document indicating ";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 7/12/2024, at 12:43 p.m., the DPCS reviewed Patient 2s record titled, ";Audit Log", dated 4/1/2024 to 7/12/2024. The record indicated the DPCS had entered notes in the physician narrative of the CTI for the certification period beginning on 3/27/2024, on 4/5/2024. Further review of the record indicated MD 1 signed the document on 5/13/2024. A record review on 7/9/2024, at 12:47 p.m., of Patient 2s record titled, ";CTI", for re-certification period of 6/25/2024 to 8/23/2024, indicated notes were entered under section ";Physician Narrative" and ";Certifying Physician Narrative". Continued review of the record did not have a signature of the doctor. During a concurrent interview and record review on 7/12/2024, at 12:43 p.m., the DPCS reviewed Patient 2s record titled, ";Audit Log", dated 4/1/2024 to 7/12/2024. The record indicated the DPCS had entered notes in the physician narrative of the CTI for the certification period beginning on 3/27/2024, on 4/5/2024. Further review of the record indicated MD 1 signed the document on 5/13/2024. 3. A review of Patient 3s ";Personal Information" sheet indicated a start of care date on 11/17/2023, with a primary diagnosis of Alzheimers disease (a progressive disease that destroys memory and other important mental functions). A record review of Patient 3s records titled ";POC/IDG", dated 6/10/2024, indicated documentation for sections ";nursing, spiritual, psychosocial". The document did not indicate the author of the entries. A record review of Patient 3s records titled ";POC/IDG", dated 6/24/2024, indicated documentation for sections ";spiritual, psychosocial". The document did not indicate the author of the entries. 4. A review of Patient 4s record titled, ";Personal Information", indicated a start of care on 4/25/2024, with a primary diagnosis of heart disease. A record review of Patient 4s records titled ";POC/IDG", dated 6/10/2024, indicated documentation for sections ";nursing, spiritual, psychosocial". The document did not indicate the author of the entries. A record review of Patient 4s records titled ";POC/IDG", dated 6/24/2024, indicated documentation for sections ";spiritual, psychosocial". The document did not indicate the author of the entries. 5. A review of Patient 5s record titled, ";Personal Information", indicated a start of care date on 3/28/2024, with a diagnosis of end stage heart failure (heart losing its ability to pump blood to the body effectively). A record review of Patient 5s records titled ";POC/IDG", dated 6/10/2024, indicated documentation for sections ";nursing, spiritual, psychosocial". The document did not indicate the author of the entries. A record review of Patient 5s records titled ";POC/IDG", dated 6/24/2024, indicated documentation for sections ";spiritual, psychosocial". The document did not indicate the author of the entries. 6. During a review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 10/15/2023 and end of care date of 5/26/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 8s medical record form titled ";Spiritual Assessment" dated 6/10/2024, indicated form was left blank and it did not have a signature. During a review of Patient 8s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 8s medical record form titled ";POC/IDG Review" dated 6/7/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 8s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 8s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #13: Re-Certification Statement for Next 60-day period" verbal authorization date 6/7/2024, indicated Medical Doctor 1s (MD1) name was listed as the referring physician attesting ";It is in my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course." The form also indicated it was not signed by MD1. During a review of Patient 8s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #13: Re-Certification Statement for Next 60-day period" effective date of certification from 6/7/2024 to 8/5/2024, indicated Medical Doctor 1s (MD1) name was listed as the physician attesting ";I certify that patients condition is terminal and may lead to death in six months or less, if the disease continues to runs its normal course." The form also indicated it was not signed by MD1. During a review of Patient 8s medical record form titled ";Comprehensive Psychosocial Assessment" dated 6/8/2024, indicated it was not signed by the author. During a review of Patient 8s medical record form titled ";Discharge Summary" dated 5/26/2024, indicated it was not signed by the author. During a concurrent interview and record review on 7/11/2024 at 12:15 p.m. with the Director of Patient Care Services (DPCS) of Patient 8s medical record, the DPCS stated Patient 8 was discharged on 5/26/2024 due to extended prognosis. DPCS stated Patient 8s discharge assessment was completed but it was not signed, therefore, the DPCS did not know who the author was. 7. During a review of Patient 9s medical record form titled ";Personal Information" indicated a start of care date of 5/27/2024, with a diagnosis of heart disease, unspecified. During a review of Patient 9s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 9s medical record form titled ";POC/IDG Review" dated 6/10/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 9s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing discussion section was left blank. The form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. 8. During a review of Patient 10s medical record form titled ";Personal Information" indicated a start of care date of 7/16/2023, with a diagnosis of Alzheimers Disease (progressive memory loss). During a review of Patient 10s medical record form titled ";Spiritual Assessment" dated 5/7/2024, indicated form was left blank and it did not have a signature. During a review of Patient 10s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 10s medical record form titled ";POC/IDG Review" dated 5/27/2024 and 6/10/2024, indicated the forms were not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 10s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing discussion section was left blank. The form also indicated it was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #12: Re-Certification Statement for Next 60-day period" effective date of certification from 7/10/2024 to 9/7/2024, indicated Medical Doctor 1s (MD1) name was listed as the physician attesting ";I certify that patients condition is terminal and may lead to death in six months or less, if the disease continues to runs its normal course." The form also indicated it was not signed by MD1. 9. During a review of Patient 11s medical record form titled ";Personal Information" indicated a start of care date of 4/26/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 11s medical record form titled ";POC/IDG Review" dated 4/26/2024, indicated the nursing documentation section was left blank. The form also indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 11s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 11s medical record form titled ";POC/IDG Review" dated 6/10/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 11s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing documentation section was left blank. The form also indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. 10. During a review of Patient 12s medical record form titled ";Personal Information" indicated a start of care date of 5/1/2024, with a diagnosis of heart disease, unspecified. During a review of Patient 12s medical record form titled ";Spiritual Assessment" dated 5/4/2024, indicated form was left blank and it did not have a signature. During a review of Patient 12s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. The form also indicated it was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 12s medical record form titled ";POC/IDG Review" dated 5/1/2024, indicated the nursing discussion section was left blank. The form also indicated it was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 12s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing discussion section was left blank. The form also indicated it was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefit – Statement for first 90-day period" verbal authorization date 5/1/2024, indicated Medical Doctor 2s (MD2) name was listed as the referring physician attesting ";It is in my clinical judgement that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course." The form also indicated it was not signed by MD2 or indicated if she wanted to follow up with the patient or not as their primary physician. During a review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" effective date of certification from 5/1/2024 to 7/29/2024, indicated Medical Doctor 1s (MD1) name was listed as the physician attesting ";I certify that patients condition is terminal and may lead to death in six months or less, if the disease continues to runs its normal course." The form also indicated it was not signed by MD1. 11. During a review of Patient 13s medical record form titled ";Personal Information" indicated a start of care date of 3/26/2023, an end of care date of 10/5/2023, with a diagnosis of heart disease, unspecified. During a review of Patient 13s medical record form titled ";Discharge Summary" dated 10/5/2023, indicated the reason for discharge was death. The form also indicated it was not signed by the author. During a review of Patient 13s medical record form titled ";Report of Death and Disposal of Controlled Drugs" dated 10/5/2023, indicated it was not signed by the author. During a concurrent interview and record review on 7/12/2024 at 1:48 p.m. with the DPCS of Patient 13s medical record, the DPCS stated he completed Patient 13s discharge summary on 10/5/2023, but signed it on 7/12/2024 at 7:42 a.m. The DPCS stated he is not aware of who completed the medical record form titled ";Report of Death and Disposal of Controlled Drugs" because it was not signed. 12. During a review of Patient 14s medical record form titled ";Personal Information" indicated a start of care date of 11/14/2023 and end of care date of 6/19/2024, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque in the heart artery causing narrowing of artery without chest pain). During a review of Patient 14s medical record form titled ";POC/IDG Review" dated 7/8/2024, indicated nursing, spiritual, psychosocial, and other/physician discussion sections were left blank. Lastly, it indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 14s medical record form titled ";POC/IDG Review" dated 6/10/2024, indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 14s medical record form titled ";POC/IDG Review" dated 6/24/2024, indicated the nursing discussion section was left blank. The form also indicated the form was not signed by the medical doctor, medical social worker, registered nurse, and chaplain. During a review of Patient 14s medical record form titled ";POC/IDG Review" dated 11/14/2023, indicated the form was not signed by the medical doctor and chaplain. During a record review of facilitys policy and procedure titled, ";Person or Entity Authentication" revised November 2021, indicated ";(HA) will use appropriate authentication methods to confirm that only properly authenticated and authorized persons or entities access ePHI. During a record review of facilitys policy and procedure titled, ";Interdisciplinary Group Meeting" revised November 2021, indicated ";Members at the interdisciplinary meeting will sign an attendance form that will be kept by the hospice Clinical Supervisor." During a record review of facilitys policy and procedure titled, ";Clinical/Service Date Collection" revised November 2021, indicated ";Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. The clinical/service note will include E. Signature or clinician/technician and his/her credentials."

Based on interview and record review the Hospice Agency (HA) HA failed to notify the attending physician of three of 14 sampled patients (Patient 8, Patient 13, and Patient 14) regarding their discharge. This failure resulted in the patients attending physician did not know about Patient 8s and Patient 14s discharges due to extended prognosis and Patient 13s discharge due to death, which further resulted to cause confusion. --- 1. During a review of Patient 8s medical record form titled ";Personal Information" indicated a start of care date of 10/15/2023 and end of care date of 5/26/2024, with a diagnosis of chronic obstructive pulmonary disease (airflow blockage, difficult breathing). During a review of Patient 8s medical record form titled ";Discharge Summary" dated 5/26/2024, indicated Patient 8 was discharge due to extended prognosis. The form also indicated it was not signed by the author. During a concurrent interview and record review on 7/11/2024 at 12:15 p.m. with the Director of Patient Care Services (DPCS) of Patient 8s medical record, the DPCS stated Patient 8 was discharged on 5/26/2024 due to extended prognosis. DPCS stated Patient 8 did not show any signs of decline after seven months of receiving hospice services. DPCS stated Patient 8s discharge assessment was completed but it was not signed, therefore, the DPCS does not know who the author was. DPCS stated there was no documentation that Patient 8s medical doctor was made aware of his discharge. 2. During a review of Patient 13s medical record form titled ";Personal Information" indicated a start of care date of 3/26/2023, an end of care date of 10/5/2023, with a diagnosis of heart disease, unspecified. During a review of Patient 13s medical record form titled ";Discharge Summary" dated 10/5/2023, indicated the reason for discharge was death. The form also indicated it was not signed by the author. During a review of Patient 13s medical record form titled ";Report of Death and Disposal of Controlled Drugs" dated 10/5/2023, indicated it was not signed by the author. During a review of Patient 13s medical record form titled ";Post Death Bereavement Support" undated, indicated the form was left blank. The form also indicated an end of care date of 10/5/2023. The form also indicated bereavement letters were overdue for Month 1 (11/5/2023), Month 3 (1/5/2024), Month 6 (4/5/2024), and Month 9 (7/5/2024). During a review of Patient 13s medical record form titled ";Post Death Bereavement Assessment" dated 10/6/2023, indicated form was left blank. During a concurrent interview and record review on 7/12/2024 at 1:48 p.m. with the DPCS of Patient 13s medical record, the DPCS stated he completed Patient 13s discharge summary on 10/5/2023, but signed it on 7/12/2024 at 7:42 a.m. 3. During a review of Patient 14s medical record form titled ";Personal Information" indicated a start of care date of 11/14/2023 and end of care date of 6/19/2024, with a diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (plaque in the heart artery causing narrowing of artery without chest pain). During a review of Patient 14s medical record form titled ";Discharge Summary" dated 6/19/2024, indicated it was left blank. Form was not completed. During a concurrent interview and record review on 7/12/2024 at 1:50 p.m. with the DPCS of Patient 14s medical record, the DPCS stated Patient 14 was discharged on 6/19/2024. DPCS stated he completed Patient 14s discharge summary on 7/10/2024 at 6:50 a.m. DPCS stated he called Patient 14s doctor the day Patient 14 was discharged but did not document the call in the medical record. DPCS stated ";The doctor needs to know that they are no longer under their care, and they have an idea where the patient is going." DPCS stated if the doctor is not made aware their patient has been discharged the patient can get hurt and not have her needs attended to. During a record review of facilitys policy and procedure titled, ";Discharge Summary" revised November 2021, indicated ";All patients discharged from a service and from hospice will have a discharge summary completed and filed in the clinical record. The discharge summary and other relevant clinical record documents will be completed and submitted within 72 hours of discharge from services." During a record review of facilitys policy and procedure titled, ";Clinical/Service Date Collection" revised November 2021, indicated ";Documentation in the clinical/service record will be timely, detailed, accurate, and reflect the care or services provided. Entries into the clinical/service record will be made on the day care/service is provided to the patient. All documentation will be turned into the office at the end of the workday. The clinical/service note will include: E. Signature or clinician/technician and his/her credentials."