Every finding on record at Golden Hospice Care, Inc

Based on interview and record review the Hospice Agency (HA) failed to ensure psychosocial services were managed and overseen by a Medical Social Worker (MSW). This failure had the potential to result in patients receiving hospice services without psychosocial services which had the potential to cause harm and distress to the patients by not having their needs met while dealing with their end of life. --- During an interview on 4/21/2025 at 12 p.m. with the Director of Patient Care Services 2 (DPCS2), the DPCS2 stated the Social Worker (SW) was hired on 4/1/2025. During a record review of the Social Worker’s (SW) employee file, on 4/22/2025, indicated the SW had a Bachelor of Arts degree (BSW) in Social Work.  During an interview on 4/22/2025, at 11:52 a.m., the DPCS 2 stated that the HA had not employed a Medical Social Worker (MSW) and was in the process of hiring one. A record review of the HA’s plan of correction (a document explaining how the HA will correct the failure and what measures it will take to prevent the failure), dated 3/26/2025, indicated the corrective action for L587 included “Moving forward, all employee records will be audited at least once a week to ensure compliance with the Agency P&P (policy and procedure).”

Based on interview and record review the Hospice Agency (HA) failed to ensure spiritual care services was provided and managed by a Spiritual Counselor. This failure had the potential to result in patients and their families/care givers are not aware of the resources needed to manage the end-of-life process. It also had the potential to cause unnecessary pain and suffering to patients’ families/care givers. --- During an interview on 4/21/2025 at 12 p.m. with the Director of Patient Care Services 2 (DPCS2), the DPCS2 stated the HA did not have a Spiritual Counselor on staff. A record review of the HA’s plan of correction (a document explaining how the HA will correct the failure and what measures it will take to prevent the failure), dated 3/26/2025, indicated the corrective action for L587 included “Moving forward, all employee records will be audited at least once a week to ensure compliance with the Agency P&P (policy and procedure).”

Based on interview and record review, the Hospice Agency (HA) failed to ensure records were not accessed by people who no longer worked at the HA for two of nine sampled patients (Patient 1, Patient 15). This failure resulted in violation of clinical records safeguarding. --- 1. During a record review of Patient 1’s medical record form titled “Personal Information” indicated a start of care date of 12/13/2024 and and end of care date of 2/4/2025, with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing).  During a record review of Patient 1’s medical record form titled “Audit Log” dated from 1/10/2025 to 4/22/2025, indicated Patient 1’s POC/IDG Review dated 4/4/2025 was electronically signed by the SC on 3/19/2025. 2. A record review of Patient 15’s Personal Information sheet indicated a start of care date on 10/25/2024 with a primary diagnosis of heart disease. The record further indicated an end of care date on 2/19/2025 for prognosis extended.  During a concurrent interview and record review on 4/22/2025, at 1:52 p.m., the Administrator (ADM) reviewed Patient 15’s "Audit Log”, dated 1/15/2025 to 4/22/2025. The record indicated the SC signed the IDG’s for 10/25/24, 11/13/24, 11/27/24, 12/11/24, 1/15/25, 1/29/25, 2/12/25, and 2/19/25 on 4/16/25. The ADM stated the SC’s last day of employment was on 3/1/2025 and did not know why the SC accessed the records on 4/16/2025. During an interview on 4/22/2025, at 1:53 p.m., the Director of Patient Care Services (DPCS 2) stated that by SC accessing Patient 15’s records on 4/16/2025, did not mean this was a HIPPA violation (privacy act regarding medical records) because even though the person was no longer working for the company, they should have access to go back and finish their documentation.

Based on interview and record review the Hospice Agency (HA) failed to provide evidence their licensed professional was qualified and licensed to provide patient care.  This failure had the potential to result in patients being taken care of unqualified and unlicensed staff which potentially can cause harm and injury to patients. --- During an interview on 4/21/2025 at 10:27 a.m., the Director of Patient Care Services 2 (DCPS 2) stated the census was zero patients. During an interview on 4/21/2025 at 10:55 a.m., the DPCS 2 stated the last active patient was discharged on 2/22/2025. During a record review of the Social Worker’s (SW) employee file, on 4/22/2025, indicated the SW had a Bachelor of Arts degree (BSW) in Social Work.  During an interview on 4/22/2025, at 11:52 a.m., the DPCS 2 stated that the HA had not employed a Medical Social Worker (MSW) and was in the process of hiring one. During a concurrent interview and record review on 4/22/2025, at 11:58 a.m., the Administrator (ADM) reviewed the SW employee file form titled Initial Competency Assessment Skills Checklist, dated 4/1/2025. The form indicated a date of hire as 4/1/2025. The record further indicated initials and a signature in the section where the supervisor signs the competency. The ADM stated the initials and signature were his. The ADM stated he was told he could sign the competency form. The ADM stated he was not a social worker nor was he a Medical Social Worker (MSW) During an interview on 4/22/2025, at 12:01 p.m., the DPCS 2 stated only an MSW knew what a social worker needed to know. An MSW needed to sign off the competency for the BSW. A record review of the HA’s plan of correction (a document explaining how the HA will correct the failure and what measures it will take to prevent the failure), dated 3/26/2025, indicated the corrective action for L783 included “moving forward, all employee records will be audited at least once a week to ensure compliance with the Agency P&P (policy and procedure).”

Based on interview and record review the Hospice Agency (HA) failed to ensure the Condition of Compliance with Federal, State and Local laws and regulations related to the health and Safety of Patients was met as evidence by: --- 1. The HA failed to notify Medicare services of a change of location, ownership, and assigned Administrator (ADM) and Director of Patient Care Services (DPCS) for nine of nine sampled patients (Patient 1, Patient 3, Patient 6, Patient 8, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 15). (Refer to L799).  The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations to ensure patients were being cared for by qualified personnel.

Based on interview and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participations regarding Patient Rights was met as follows: --- 1. Based on interview, and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure one of 14 sampled patients (Patient 11) receive information regarding their rights and responsibilities as a hospice patient in a language that would be understood and preferred by the patient. (Refer to L502). 2. The HA failed to ensure six of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, and Patient 8) rights to refuse care or treatments as documented on their Physician Orders for Life-Sustaining Treatment (POLST – a medical order that specifies a patients end of life care preference) were authenticated by the Medical Director 1 (MD1). (Refer to L 514). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated Federal compliance for Patient Rights to ensure their rights are not violated and receive the highest quality of hospice care services.

Based on interview, and record review the Hospice Agency (HA, agency providing care to terminally ill patients who have six months or less to live) failed to ensure one of 14 sampled patients (Patient 11) receive information regarding their rights and responsibilities as a hospice patient in a language that would be understood and preferred by the patient. This deficient practice resulted in the patient not fully informed and lack of understanding of the hospice care and services available for the patients and their families which resulted to the violation of the patient's right to decline the hospice services. --- A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain) and indicated Spanish as the primary language. A review of Patient 11s physical medical record indicated Consent and Patient Right and Responsibilities forms in English wording and noted with Patient 11s signature dated 11/6/2024. During a phone interview on 1/8/2025 at 12:19 pm with Patient 11, Patient 11 was speaking Spanish and stated he only speaks Spanish and prefers paperwork provided to him to be in Spanish. Patient 11 further stated the Hospice Agency (HA) Skilled Nurse (SN) provided him with English Consent forms that SN read aloud to him to sign. Patient 11 stated he was unable to read consent forms because they were in English wording. During a concurrent interview and record review on 1/10/2025 at 4:37 pm, with the Director of Patient Care Services (DPCS), Patient 11s medical records, Informed Consents and Patient rights and responsibilities dated 11/6/2024 were reviewed. The DPCS stated and confirmed Patient 11s Informed Consents and Patient Rights and Responsibilities forms were in English wording and signed by Patient 11 dated 11/6/2024. The DPCS further stated it is important to provide all patient with consent and patient rights and responsibilities form in their language, so the patient understands why and what they are signing up for, especially if they cannot understand English. During a review of the HAs Policy and Procedure (P&P) titled, Informed Consent/Refusal of Treatment, with a revised date of April 2019, indicated, ";Upon admission and throughout course of care/service, the patient and family/caregiver will be: 1. Given information, in an understandable language, to make informed decisions regarding the care/services being provided." During a review of the HAs P&P titled, Patient Bill of Rights/Responsibilities, with a revised date of April 2019, indicated, ";3. The Patient Bill of Rights/Responsibilities will be explained (verbally/orally) and distributed to the patient prior to the initiation of organization services. This explanation will be in a language and manner he/she can reasonably be expected to understand... 6. The admitting clinician will document that the patient has received a copy of the Patient Bill of Rights/Responsibilities. C. Written information will be provided to patients in the predominant languages of the population served."

Based on interview and record review the Hospice Agency (HA) failed to ensure six of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, and Patient 8) rights to refuse care or treatments as documented on their Physician Orders for Life-Sustaining Treatment (POLST – a medical order that specifies a patients end of life care preference) were authenticated (verifies and confirms the accuracy of the medical order) by the Medical Director 1 (MD1). This failure had the potential to result in patients end of life rights are not recognized per their last wishes. --- 4. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a record review of Patient 6s medical record form, titled ";Comprehensive Nursing Assessment," dated 12/12/2024, the ";Comprehensive Nursing Assessment" indicated Patient 6 was alert, oriented to self, place, and time. The ";Comprehensive Nursing Assessment" indicated Patient 6 was able to verbalize needs and concerns. During a record review of Patient 6s medical record form, titled ";Physician Orders for Life-Sustaining Treatment (POLST), dated 12/12/2024, the POLST indicated it was a ";Physician Order Sheet based on the persons current medical condition and wishes." The POLST indicated no physician signed the Patient 6s form. The POLST indicated Patient 6 wishes: ";Do Not Attempt Resuscitation (DNR, allow natural death)," ";Comfort Measures Only," and ";No artificial nutrition by tube." During a concurrent interview and record review of Patient 6s medical records on 1/7/2024 at 2:14 PM with DD, Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, and physician's orders were reviewed. DD stated Patient 6 was receiving hospice services without a physicians admission order. DD stated the Patient 6s POLST was not considered ";valid" due to the missing physicians signature. DD stated the licensed nurse must then perform full treatment, including resuscitation, in case Patient 6 did not have a pulse and was not breathing. 5. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease (long-term heart problems due to high blood pressure) with heart failure. During a record review of Patient 7s medical record form, titled ";Comprehensive Nursing Assessment," dated 11/26/2024, the ";Comprehensive Nursing Assessment" indicated Patient 7 was alert, oriented to self, place, and time; and was able to verbalize needs and concerns. During a record review of Patient 7s medical record form, titled ";Physician Orders for Life-Sustaining Treatment (POLST), dated 11/26/2024, the POLST indicated it was a ";Physician Order Sheet based on the persons current medical condition and wishes." The POLST indicated no physician signed the Patient 7s form. The POLST indicated Patient 7 wishes: ";Do Not Attempt Resuscitation (DNR, allow natural death)," ";Comfort Measures Only," and ";No artificial nutrition by tube." During a concurrent interview and record review of Patient 7s medical records on 1/7/2024 at 2:14 PM with DD, Patient 7s ";Comprehensive Nursing Assessment," dated 11/26/2024 and physicians orders were reviewed. DD stated Patient 7 was receiving hospice services without a physicians admission order. DD stated the Patient 7s POLST was not considered ";valid" due to the missing physicians signature. DD stated the licensed nurse must perform full treatment, including resuscitation, in case Patient 7 did not have a pulse and was not breathing. 6. During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease that causes difficulty breathing). During a record review of Patient 8s medical record form, titled ";Comprehensive Nursing Assessment," dated 11/25/2024, the ";Comprehensive Nursing Assessment" indicated Patient 8 was alert, oriented to self, place, and time; and was able to verbalize needs and concerns. During a record review of Patient 8s medical record form, titled ";Physician Orders for Life-Sustaining Treatment (POLST), dated 11/25/2024, the POLST indicated it was a ";Physician Order Sheet based on the persons current medical condition and wishes." The POLST indicated no physician signed the Patient 8s form. The POLST indicated Patient 8 wishes: ";Do Not Attempt Resuscitation (DNR, allow natural death)," ";Comfort Measures Only," and ";No artificial nutrition by tube." During a concurrent interview and record review of Patient 8s medical records on 1/7/2024 at 2:14 PM with DD, Patient 8s ";Comprehensive Nursing Assessment," dated 11/25/2024 and physicians orders were reviewed. DD stated Patient 8 was receiving hospice services without a physicians admission order. DD stated the Patient 8s POLST was not considered ";valid" due to the missing physicians signature. DD stated the licensed nurse must perform full treatment, including resuscitation, in case Patient 8 did not have a pulse and was not breathing. During a record review of the HAs policy and procedures (P&P), titled ";Patient Bill of Rights/Responsibilities," dated 4/2019, the P&P indicated the patient must be empowered with certain rights and responsibilities to ensure each patient would be an active, informed participant in his/her plan of care. The P&P indicated each patient has the right to refuse care or treatment after the consequences of refusing care or treatment are fully presented. The P&P indicated each patient has the right to receive care/service without discrimination in accordance with physician orders. During an interview on 1/7/2025 at 1 p.m., with the Director of Patient Care Service Designee (DD) stated patients POLST were physician orders, of what the patient wants done if something happens to them. During an interview on 1/8/2025 at 1:25 p.m. with the Director of Patient Care Service (DPCS), the DPCS stated POLST serves as a patients guide on their end of life wishes. The DPCS stated when a patient deteriorates and there is no POLST to guide the HA staff, the patients last wishes will not be rendered. The DPCS stated if a patient elects not to be resuscitated (a medical order that instructs healthcare providers not to perform cardiopulmonary resuscitation) but there is no POLST to follow the HA staff will treat the patient as a full code (a medical directive that instructs a patients healthcare team to perfume all possible resuscitation efforts if the patients heart and lungs stop working) thereby not respecting the patients wishes. The DPCS stated that when patients POLST are not signed by a physician they are not valid. The DPCS stated MD1 usually signs the patients POLST during the in person interdisciplinary group (IDG) meeting. The DPCS stated their last in person IDG meeting was held on 11/27/2024. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a concurrent interview and record review on 1/7/2025 at 12:04 p.m., with the DD of Patient 1s Electronic Medical Record (EMR) and physical medical record, DD stated Patient 1s POLST was not signed by the MD1. The DD stated that the MD1 needed to sign Patient 1s POLST to attest that those are Patient 1s last wishes. During an interview on 1/8/2025 at 7:57 a.m., with Patient 1, Patient 1 stated he was not a hospice patient. Patient 1 stated he wants to live a ";little bit" longer and he has not been told he had six months or less to live. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). During a concurrent interview and record review on 1/7/2025 at 1 p.m., with the DD of Patient 2s electronic and physical medical record, DD stated Patient 2s POLST was not valid because the MD1 had not sing it. During an interview on 1/8/2025 at 8:12 a.m. with Patient 2, Patient 2 stated he was not dying and that no one told him (Patient 2) that he was dying. 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s electronic and physical medical record, DD stated Patient 3s POLST was not complete because it was missing the MD1s signature.

Based on observation, interview and record review, the Hospice Agency (HA) failed to ensure the Conditions of Participation regarding Initial and Comprehensive Assessments of Patients was met as follows: --- 1. The HA staff failed to conduct and document an accurate initial assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, and Patient 11). This failure resulted in patients being admitted and certified for hospice care without addressing their immediate care needs which are necessary in the management of the terminal illness that could affect their quality of life. (Refer to L 522). 2. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessment no later than 5 calendar days after election of hospice care for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 10, Patient 12, and Patient 13). (Refer to L 523). 3. The HA failed to ensure twelve of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) receive an initial bereavement assessment. (Refer to L 531). 4. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) met and updated the comprehensive assessment at least every 15 days for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 10, Patient 11, Patient 12, and Patient 13). (Refer to L 533). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver mandated compliance with the Federal regulations for Initial and Comprehensive Assessment of Patients that resulted to admitting patients who did not meet the certification requirement to receive the hospice care benefits.

Based on interview and record review the Hospice Agency (HA) staff failed to conduct and document an accurate initial assessment that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, and Patient 11). This failure resulted in patients being admitted and certified for hospice care without addressing their immediate care needs which are necessary in the management of the terminal illness that could affect their quality of life. --- 7. A review of Patient 11s ";Personal Information" document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). During a record review of Patient 1s medical record form titled ";Physician Order" undated, did not indicate there were physician's admission or treatment orders. A review of Patient 11s medical record form titled ";LCD Hospice Eligibility Determination" dated 11/6/2024, indicated Patient 11s qualifying factors included 1a. patient has been ruled out as a candidate for surgical procedures, 1b. patient has declined surgical procedures, 1c. patient optimally treated for heart disease with diuretics (medication that increases urine output by kidneys to help body get rid of excess water and salt) and vasodilators (medication to open your blood vessels), 2a. the CHF (congestive heart failure, heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) or angina (chest pain) patient meets the criteria for NYHA Class IV level, and 3b. has history of cardiac arrest (heart stopped) or resuscitation. During a review of Patient 11s medical record form titled ";Comprehensive Nursing Assessment" dated 11/6/2024, indicated Patient 11 had apical pulse, pedal pulse, and radial pulse irregular and weak. The form indicated the SNs narrative documentation included Patient 11s co-morbidities including type 1 diabetes (high blood sugar), hypertension (high blood pressure), hyperlipidemia (high cholesterol). The SNs documented narrative also indicated, ";Hospice philosophy, disease progression, symptom management, and comfort care reviewed with the patient and PCG (patient caregiver)... Consent forms were signed, and PCG was informed of 24-hour hospice support availability." The form indicated it was electronically signed by the SN on 11/6/2024. During a record review of Patient 11s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a concurrent interview and record review on 1/7/2025 at 4:00 p.m. with the Director of Patient Care Services Designee (DD), Patient 11s Electronic Medical Record (EMR) and physical medical record were reviewed. The DD stated Patient 11 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 11s medical records did not contain her history and/or physical, or hospital records therefore, the Hospice Agency (HA) does not have any evidence to support Patient 11s documented LCD. A review of Patient 11s medical record titled, Comprehensive Nursing Assessment dated 11/6/2024, indicated Registered Nurse 2 (RN 2) narrative documentation included Patient 11s functional status and care needs as requiring considerable assistance and frequent medical care, mainly sits or lies down, unable to work, requires extensive assistance, with evidence of disease progression, difficulty traveling to new locations. Patient 11s Comprehensive Nursing Assessment indicated an electronic signature from RN 2 dated 11/6/2024. During a phone interview on 1/8/2025 at 12:19pm with Patient 11 stated, he was not referred to hospice services but was approached by a lady from the HA on the street and offered in home services for a nurse to visit him weekly and provide him with medication and refills. Patient 11 stated he has a primary physician who he continues to see and is not aware of the services he is receiving from the HA. Patient 11 stated he has a left below the knee amputation and moves around in a scooter, but is able to care for himself, cook, wash, and likes to go out on his scooter. Patient 11 stated he does not need nurses to come care for him, that he is able to do that himself, he just needs to be provided with his medication that he cannot afford. Patient 11 stated he explained that to the lady from the HA who approached him on the street. Patient 11 further stated he was not explained what hospice services were by the SN and has never been told by his primary physician that he has a terminal illness. During a joint home visit on 1/9/2025 at 1:30 pm., at Patient 11s home with California Department of Public Health 3 (CDPH 3), Patient 11 was observed not to be home and Patient 11s sister stated Patient 11 likes to get out of the house on his scooter. Patient 11 was contacted via phone call and stated he was not evaluated by a SW from the HA, was not offered chaplain services or therapy, and being homebound was not addressed. 6. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a record review of Patient 6s medical record form, titled ";Physicians Certification for Hospice Benefit – Statement for First 90-day period," dated 12/12/2024, indicated RN 1 obtained verbal authorization from the MD 2 to admit Patient 6 for hospice services. The form indicated MD 2 did not sign the form. The form did not indicate if MD 2 wanted to follow Patient 6s care or not. Lastly, the form indicated, ";It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice." During a record review of Patient 6s medical record form, titled ";Comprehensive Nursing Assessment," dated 12/12/2024, the ";Comprehensive Nursing Assessment" indicated the following: 1. Patient 6 was alert and oriented to self, place, and time. Patient 6 was able to verbalize needs and concerns. 2. Patient 6 was continent of urine. 3. Patient 6 required ";occasional assistance" but was able to care for most of her personal needs 4. Patient 6 was able to ambulate with a cane or a walker. During a record review of Patient 6s medical record form titled ";Audit Log" dated from 12/12/2024 to 1/10/2025, indicated RN 1 signed Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, on 12/23/2024. During a record review of Patient 6s medical record form titled ";LCD Hospice Eligibility Determination," dated 12/12/2024, it indicated Patient 6 did not qualify per LCD guidelines. The ";LCD Hospice Eligibility Determination" indicated Patient 6 did not meet the following qualifying factors: 1. Unable to dress without assistance. 2. Unable to bathe without assistance. 3. Urinary and fecal incontinence (inability to voluntary control urine or bowel movement) is intermittent or constant/dependent on catheter (thin, flexible tube that can be inserted into the body) or ostomy (surgical opening in the body to help remove waste) care. 4. Unable to consistently have meaningful verbal communication; utters stereotypical phrases only, or ability to speak six or fewer intelligible words. The ";LCD Hospice Eligibility Determination" indicated Patient 6 had inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous 6 months or serum albumin (laboratory test that measures the protein in the blood that helps maintain fluid balance) was less than 2.5 grams per deciliter. During a concurrent interview and record review of Patient 6s medical records on 1/7/2024 at 2:14 PM with DD Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, ";CTI," dated 12/13/2024, ";LCD Hospice Eligibility Determination," dated 12/12/2024, and physicians orders were reviewed. DD stated there was no documented evidence that Patient 6 had inability to maintain sufficient fluid and caloric intake with 10% weight loss during the previous 6 months or serum albumin level less than 2.5 gm/dl. DD stated the lack of objective data could lead to Patient 6s inaccurate assessment and would not support Patient 6s eligibility for hospice services. DD stated RN 1 conducted the initial home visit assessment for Patient 6 on 12/12/2024. DD stated Patient was receiving hospice services without a physicians admission order. During an interview on 1/10/2025 at 11:57 AM, the DPCS stated the Administrator, who was not a licensed nurse or physician, was responsible for determining a patients (in general) eligibility for hospice services. The DPCS stated she has not communicated with the referring physician or healthcare facility to request for the patients (in general) medical records to determine and support hospice eligibility. The DPCS stated she ";assumed" the Administrator had requested the medical records prior to the patients (in general) admission to HA 1. The DPCS stated she reviewed the hospice eligibility based on the admitting Registered Nurses (RNs) ";Comprehensive Nursing Assessment." During an interview on 1/10/2025 at 1:41 PM, Registered Nurse 1 (RN 1) stated the Administrator would inform RN 1 if a patient (in general) would be admitted to HA 1. RN 1 stated HA 1 would provide the patients name, address, and complaints. RN 1 stated he conducted his ";Comprehensive Nursing Assessment" based on the patients (in general) and/or caregivers responses. RN 1 stated he did not review the patients (in general) medical records from the hospital or any documentation from any healthcare facility. RN 1 was not able to provide a reason for the late upload of Patient 6s initial nursing assessment. During an interview on 1/10/2025 at 3:01 PM, the Administrator (ADM) stated he reviewed all patient referrals. ADM stated he obtained his patient referrals from the ";clinics, hospitals, and personal referrals." ADM stated Patient 6 was referred by Referral Person (RP) who ";worked at a clinic." ADM was unable to present any documented evidence of a referral from a clinic or a hospital that included Patient 6s medical records that supported Patient 6s eligibility to receive hospice services. 7. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease (long-term heart problems due to high blood pressure) with heart failure. During a record review of Patient 7s medical record form, titled ";Physicians Certification for Hospice Benefit – Statement for First 90-day period," dated 11/26/2024, indicated RN 1 obtained verbal authorization from the MD 2, to admit Patient 7 for hospice services. The form indicated MD 2 did not sign the form. The form did not indicate if MD 2 wanted to follow Patient 7s care or not. Lastly, the form indicated, ";It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice." During a record review of Patient 7s medical record form, titled ";Comprehensive Nursing Assessment," dated 11/26/2024, the ";Comprehensive Nursing Assessment" indicated the following: 1. Patient 7 was alert; oriented to self, place, and time; and was able to verbalize needs and concerns. 2. Patient 7 had normal systolic blood pressure (SBP, measure of the force of blood pushing against artery walls during heart contraction with normal levels less than 120 mmHg) at 91-159. 3. Patient 7 had regular apical pulse (heart rate obtained by listening directly to the heartbeat using a stethoscope), pedal pulse (heart rate obtained by palpating the foot or using an ultrasound device) and radial pulse (heart rate obtained by palpating the radial artery of the wrist). 4. Patient 7 has no cardiac-related (heart-related) pain. 5. Patient 7 had a 2+ edema (slight swelling in the tissues due to fluid buildup with 4+ being most severe) to both lower extremities. 6. Patient 7 had mild dyspnea (SOB, shortness of breath) with mild exertion. 7. Patient 7 had normal respirations (breathing) with no cough. 8. Patient 7 ";required occasional assistance" but was able to care for most of his personal needs. During a record review of Patient 7s medical record form titled ";Audit Log" dated from 11/26/2024 to 1/10/2025, indicated RN 1 signed Patient 7s ";Comprehensive Nursing Assessment" dated 11/26/2024, on 12/2/2024. During a record review of Patient 7s medical record form titled ";LCD Hospice Eligibility Determination," dated 11/26/2024, it indicated Patient 7s qualifying factors included: 1. Patient optimally treated for heart disease with diuretics (medications that increase urine production to get rid of excess fluid) and vasodilators (medications that open blood vessels to increase blood flow to organs). 2. Patient meet the criteria for New York Heart Association (NYHA) Class IV level (most severe class of heart failure resulting in inability to carry on physical activity without discomfort due to symptoms of heart failure at rest or with minimal exertion). During a concurrent interview and record review of Patient 7s medical records on 1/7/2024 at 2:14 PM with DD, Patient 7s ";Comprehensive Nursing Assessment," dated 11/26/2024, ";CTI," dated 11/26/2024, ";LCD Hospice Eligibility Determination," dated 11/26/2024, and physicians orders were reviewed. DD stated RN 1 documented that Patient 7 met the criteria for NYHA Class IV level but lacked documented evidence to support Patient 7s eligibility for hospice services. DD stated RN 1 conducted the initial home visit assessment for Patient 7 on 11/26/2024. DD stated Patient 7 was receiving hospice services without a physicians admission order. During an interview on 1/8/2025 at 11:25 AM, Licensed Vocational Nurse 1 (LVN 1) stated LVN 1 did not ";find" Patient 7 at the location on file when LVN 1 conducted the Skilled Nursing (SN) visit in 12/2024 (unable to recall exact date). LVN 1 stated the ";staff" at the location did not know Patient 7. LVN 1 stated she was not able to contact Patient 7 via the phone number on file. During an interview on 1/10/2025 at 1:41 PM, RN 1 stated Patient 7 had a different phone number from the phone number listed on file. RN 1 stated Patient 7 lived in an apartment with about 6 to 8 units. RN 1 stated he identified Patient 7 has NYHA Class IV level because Patient 7 had ";SOB after walking for a long time from the kitchen to the living room," had ";congested lungs," and had a ";history of chest pain and heart attack." RN 1 was unable to state the specific criteria to determine qualifications for NYHA Class III or a Class IV level. RN 1 stated he did not review any medical records from Patient 7, HA, or from the hospital/clinic. RN 1 was not able to provide a reason for the late upload of Patient 7s initial nursing assessment. During an interview on 1/10/2025 at 3:01 PM, ADM stated Patient 7 was referred by RP who ";worked at a clinic." ADM was unable to present any documented evidence of a referral from a clinic or a hospital that included Patient 7s medical records that supported Patient 7s eligibility to receive hospice services. During an interview and concurrent observation on 1/10/2025 at 4:47 PM with the DPCS, Patient 7s phone number provided by RN 1 was called. DPCS stated the phone number did not exist, and HA did not have Patient 7s correct phone number for the staff to contact upon delivery of care and services. 8. During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease that causes difficulty breathing). During a record review of Patient 8s medical record form, titled ";Physicians Certification for Hospice Benefit – Statement for First 90-day period," dated 11/25/2024, indicated RN 1 obtained verbal authorization from the MD 2 to admit Patient 8 for hospice services. The form indicated MD 2 did not sign the form. The form did not indicate if MD 2 wanted to follow Patient 8s care or not. Lastly, the form indicated, ";It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice." During a record review of Patient 8s medical record form, titled ";Comprehensive Nursing Assessment," dated 11/25/2024, the ";Comprehensive Nursing Assessment" indicated the following: 1. Patient 8 was alert; oriented to self, place, and time; and was able to verbalize needs and concerns. 2. Patient 8 had episodes of severe SOB by walking to the front door of his house. 3. Patient 8 had moderate SOB with mild exertion, labored respirations with crackles (abnormal lung sounds) but no coughing. 4. Patient 8 was on oxygen therapy at 2 liters per minute via nasal cannula (thin, flexible tube that delivers supplement oxygen through the nose). 5. RN 1 did not document whether Patient 8s oxygen therapy was administered continuously or as needed. 6. RN 1 did not document Patient 8s oxygen saturation (amount of oxygen in the blood with normal values ranging from 95% to 100% that could be obtained via pulse oximetry (non-invasive method that measures the amount of oxygen in the blood). During a record review of Patient 8s medical record form titled ";Audit Log" dated from 11/25/2024 to 1/7/2025, indicated RN 1 signed Patient 8s ";Comprehensive Nursing Assessment" dated 11/25/2024, on 12/2/2024. During a record review of Patient 8s medical record form, titled ";LCD Hospice Eligibility Determination," dated 11/25/2024, it indicated Patient 8s qualifying factors included: 1. Poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. 2. Increasing visits to the emergency room. 3. Hypoxemia (low level of oxygen in the blood) at rest on room air, as evidenced by pO2 (pO2, measure of the tension or pressure of oxygen dissolved in the blood obtained through a blood test or pulse oximetry) less than or equal to 55 millimeters of mercury (mmHG, unit of measurement of pressure). During a concurrent interview and record review of Patient 8s medical records on 1/7/2024 at 2:14 PM with DD, Patient 8s ";Comprehensive Nursing Assessment," dated 11/25/2024, ";CTI," dated 11/25/2024, ";LCD Hospice Eligibility Determination," dated 11/25/2024, and physicians orders were reviewed. DD stated RN 1 documented Patient 8 had ";hypoxemia at rest on room air, but there was no documented evidence of pO2 in Patient 8s medical records. DD stated RN 1 conducted the initial home visit assessment for Patient 8 on 11/25/2024. DD stated Patient 8 was receiving hospice services without a physicians admission order. During an interview on 1/10/2025 at 1:41 PM, RN 1 stated he did not review any medical records from Patient 8, HA, or from the hospital/clinic. RN 1 was not able to provide a reason for the late upload of Patient 8s initial nursing assessment. During an interview on 1/10/2025 at 3:01 PM, ADM stated Patient 8 was referred by RP who ";worked at a clinic." ADM was unable to present any documented evidence of a referral from a clinic or a hospital that included Patient 8s medical records that supported Patient 8s eligibility to receive hospice services. During an interview on 1/10/2025 at 12:30 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she based the patients' care plans on the initial nursing assessment. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The form also indicated section ";Allergies" was left blank. Lastly, the form indicated Medical Director 1 (MD1) was listed under ";Medical Director" and Medical Doctor 2 (MD2) was listed under ";Referring/Attending/Patient Choice". During a record review of Patient 1s medical record form titled ";Physician Order" dated 1/4/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 1s medical record form titled ";LCD Hospice Eligibility Determination" dated 12/13/2024, indicated Patient 1s qualifying factors included 1. Poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. 2. Increased visit to the emergency room. 3. Oxygen saturation less than or equal to 88% determined either by arterial blood gases or oxygen saturation monitors (these values may be obtained from recent hospital records) and 4. Unintentional progressive weight loss > or = 10% of body weight over last six months. During a record review of Patient 1s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 1s oxygen saturation was at 96%, but it does not indicate if his oxygen reading was with the use of oxygen or not. The form did not indicate who Patient 1s caregiver was or if he had any allergies to food or medication. The form indicated Registered Nurse 1 (RN1)s narrative documentation included Patient 1s co-morbidities including diabetes (high blood sugar), arthritis (joint pain), scoliosis (abnormal spine curvature), and hypertension (high blood pressure). Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 1s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a record review of Patient 1s medical record form titled ";History of Psychosocial Assessment" undated, indicated there were no entries made. During a record review of Patient 1s electronic and physical medical record, indicated there was no psychosocial or bereavement assessments documented. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m., with the Director of Patient Care Services Designee (DD) of Patient 1s Electronic Medical Record (EMR) and physical medical record, the DD stated Patient 1s start of care date was 12/13/2024. The DD stated Patient 1 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 1 was receiving oxygen from the HA without a physicians order. The DD stated Patient 1s diabetes was not being assessed by the HA. The DD stated she did not know if the family was managing Patient 1s diabetes. The DD stated Patient 1 can experience confusion, coma, or death if his blood sugar goes too high or too low. The DD stated diabetes complications can be prevented if managed correctly. The DD stated Patient 1s medical records did not contain his history and/or physical, therefore, the HA does not have any evidence to support Patient 1s documented LCD. During an interview on 1/8/2025 at 7:57 a.m., with Patient 1, Patient 1 stated he was not receiving hospice services. Patient 1 stated he was not a hospice patient and that he wants ";to live a little bit longer". Patient 1 stated he was in the middle of changing primary physician. Patient 1 stated he has not heard of MD1 or MD2. Patient 1 stated he had never heard of RN1s name. During an interview on 1/8/2025 at 10:50 a.m., with RN1, RN1 stated he conducted Patient 1s initial assessment on 12/13/2025 and has seen Patient 1 for two or three visits. RN1 stated requesting Patient 1s medical records from his primary physician, Patient 1 and from the HAs Administrator (ADM) and DPCS. RN1 stated he reviews patients medications and if they have medications for diabetes, he asks about it. RN1 stated Patient 1 ";probably" told him what his blood sugar reading was, but RN1 did not document that. RN1 stated Patient 1 informed RN1 that his big problem was his breathing. RN1 stated he spoke with MD2 about Patient 1 at which time he received verbal orders from MD2. RN1 was unable to provide MD2s phone number. During a concurrent interview and record review on 1/8/2025 at 12:10 p.m., with the DPCS of Patient 1s EMR and physical medical record, the DPCS stated RN1 provided Patient 1s initial home visit assessment on 12/13/2024 but signed it on 12/26/2024. The DPCS stated Patient 1s initial psychosocial and bereavement assessments were not done. The DPCS stated she did not know what Patient 1s allergies were because they were not listed on his medical record. The DPCS stated Patient 1 was receiving hospice services without a physician's admission order. During an interview on 1/8/2025 at 12:35 p.m. with the ADM of Patient 1s EMR and physical medical record, the ADM stated MD2 was Patient 1s referring doctor and needed to sign the admitting orders. During a concurrent interview and record review on 1/8/2025 at 12:35 p.m. with the DPCS of Patient 1s EMR and physical medical record, the DPCS stated Patient 1 does not have any treatment orders. The DPCS stated it was important to have completed patient documents for liability reasons. The DPCS stated the HA did not have Patient 1s history and physical, or any documented evidence that supports the admitting nurses assessment. The DPCS stated there were no documented evidence to attest to Patient 1s assessment. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). The form also indicated section ";Allergies" was left blank. Lastly, the form indicated MD1 was listed under ";Medical Director" and MD2 was listed under ";Referring/Attending/Patient Choice". During a record review of Patient 2s medical record form titled ";Physician Order" dated 12/19/2025, indicated no physician's admission or treatment orders. During a record review of Patient 2s medical record form titled ";LCD Hospice Eligibility Determination" dated 12/13/2024, indicated Patient 2s qualifying factors included 1. Is patient optimally treated for heart disease with diuretics and vasodilators. 2. Does this CHF or angina patient meet the criteria for New York Heart Association (NYHA – a system for categorizing the severity of heart failure based on a patients physical activity limitations) Class IV (unable to carry out any physical activity without discomfort) level. During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 2 was alert, oriented and able to verbalize pain. The form also indicated Patient 2 required moderate assistance with ambulation, toileting, dressing, feeding, and bathing and was complete dependent when transferring. The form also indicated Patient 2 had a NYHA class level of IV. The form also indicated under the Cardiovascular section that Patient 2 had a regular pulse rate, and had +1 pitting level edema, but it does not state where the pitting edema was located. Section ";cardiac-related pain" under Cardiovascular was left blank. The form indicated RN1s narrative documentation included Patient 2s co-morbidities including diabetes, arthritis, depression, and open-heart surgery. RN1s documented narrative also included ";Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort." The form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 2s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a record review of Patient 2s electronic and physical medical record, indicated there was no bereavement assessment documented. During a concurrent interview and record review on 1/7/2025 at 1 p.m., with the DD of Patient 2s EMR and physical medical record, the DD stated Patient 2s start of care date was 12/13/2024. The DD stated Patient 2 did not have admission or treatment physician's orders which were needed to be able to treat the patient. The DD stated Patient 2s medical records did not contain history and/or physical therefore, the HA does not have any evidence to support Patient 2s documented LCD. During an interview on 1/8/2025 at 8:12 a.m. with Patient 2, Patient 2 stated he was not dying, and that no one ever told him he was dying. Patient 2 stated he was referred by a friend of a friend, who also told him that he would get nutrition supplement and a blood sugar reading machine. Patient 2 stated he sees a cardiologist and a primary doctor (MD3). Patient 2 stated I am not dying, only God knows when Ill die. During an interview on 1/8/2025 at 10:45 a.m. with License Vocational Nurse 1 (LVN1), LVN1 stated she visited Patient 2 twice. LVN1 stated she did not follow Patient 2s plan of care because she did not have it. LVN1 stated she checked Patient 2s blood pressure, when his last bowel movement was, if he was experiencing any medication side effects, if he had any falls, how his sleeping and appetite were, and if there were any changes to report. LVN1 stated Patient 2 can ambulate by himself but should use a walker. LVN1 stated Patient 2 can eat, transfer, and able to use restroom by himself. LVN1 stated Patient 2 will be seeing his primary physician either in March or April 2025. During an interview on 1/8/2025 at 11 a.m., with MD3 stated, she was Patient 2s primary physician. MD3 stated she last saw Patient 2 on 11/14/2024. MD3 stated she did not refer Patient 2 for hospice services. MD3 stated Patient 2 has chronic illnesses but is a ";pretty healthy man". During a concurrent interview and record review on 1/8/2025 at 12:45 p.m. with the DPCS of Patient 2s EMR and physical medical record, the DPCS stated RN1 documented Patient 2s LCD form incorrectly. The DPCS stated Patient 2 was not taking diuretics (medication to eliminate water from body). The DPCS stated Patient 2s medical record did not indicate his diabetes was being assessed. The DPCS stated Patient 2 has a risk of going into diabetic ketoacidosis (a metabolic condition that occurs when there is a buildup of ketose in the blood which can be life threatening). 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. The form also indicated section ";Allergies" was left blank. Lastly, the form indicated MD1 was listed under ";Medical Director" and MD2 was listed under ";Referring /Attending/Patient Choice". During a record review of Patient 3s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate a physician's admission or treatment orders. During a record review of Patient 3s medical record form titled ";LCD Hospice Eligibility Determination" dated 12/13/2024, indicated Patient 3s qualifying factors included 1. Poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. 2. Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, less than 30% of predicted. 3. Increased visit to the emergency room and 4. Oxygen saturation less than or equal to 88% determined either by arterial blood gases or oxygen saturation monitors (these values may be obtained from recent hospital records). During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 3 was not receiving oxygen. The form also indicated Patient 3 required moderate assistance with toileting, dressing, feeding, and bathing and was complete dependent when transferring and ambulating. The form also indicated under the Cardiovascular section that Patient 3 had +2 pitting level edema, but it does not state where the pitting edema was located. The form indicated RN1s narrative documentation included Patient 3s co-morbidities including diabetes, arthritis, gastritis (stomach pain) and osteoporosis (weak and brittle bones). RN1s documented narrative also included ";The patients caregiver verbalized understanding regarding the Election of Hospice Benefits and elected MD as the attending physician... The patients current condition, medication, and treatments have been recorded and reviewed with MD via telephone and ordered to continue the medications and treatments upon admission." Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 3s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a record review of Patient 3s medical record form titled ";History of Psychosocial Assessment" undated, indicated there were no entries made. During a record review of Patient 3s electronic and physical medical record, indicated there was no psychosocial or bereavement assessments documented. During a record review of Patient 3s Center for Medical and Medicare (CMS) form 807 (form used by a California Department of Public Health (CDPH) employee to document any interview, observation, or record review of a patient during a survey and/or investigation), Patient 3s CMS form 807 was completed by CDPH Employee 1 (CDPH1), CDPH1 documented she visited Patient 3 on 1/9/2025. CDPH1 documented Patient 3 did not know she was sick and did not know she required hospice services. CDPH1 documented Patient 3 stated License Vocational Nurse 1 (LVN1) visits every two weeks. CDPH1 documented Patient 3 has a primary physician (MD4) who she will see on 1/17/2025. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s EMR and physical medical record, the DD stated Patient 3s start of care date was 12/13/2024. The DD stated Patient 3 was not receiving oxygen from the HA. The DD stated Patient 3s diabetes was not being assessed. The DD stated Patient 3s medical records did not contain her history and/or physical, therefore, the HA does not have any evidence to support Patient 3s documented LCD. During a concurrent interview and record review on 1/8/2025 at 1 p.m. with the DPCS of Patient 3s EMR and physical medical record, the DPCS stated RN1 provided Patient 3s initial home visit assessment on 12/13/2024. The DPCS stated Patient 3 was receiving hospice services without a physician's admission or treatment orders. The DPCS stated Patient 3s medical record did not contain documented evidence to support RN1s documentation. During an interview on 1/8/2025 at 10:45 a.m. with LVN1, LVN1 stated she visits Patient 3 and Patient 3s sister at their home every other week. LVN1 stated Patient 3 might have a walker (a walking assistive device), but she did not see it while doing a home visit.

Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) complete the comprehensive assessments no later than 5 calendar days after election of hospice care for nine of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 10, Patient 12, and Patient 13). This failure resulted in patients not being properly evaluated which resulted in not being provided the individualized patient care services. --- During an interview on 1/7/2025at 2:50 pm., with the MSW stated, he was made aware of new patients to the HA via Interdisciplinary Team (IDT) meetings or via the HAs EMR. The MSW further stated once a patient is assigned to him, the MSW has five days to contact the patient, family, or caregiver, visit the patient and fill out the psychosocial assessment. The MSW stated it is important to assess and complete a patients psychosocial assessment because the way a patient feels relates to their medical condition and providing them, as well as the family/caregiver counseling can positively encourage them. 7. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). A review of Patient 10s Electronic Medical Record (EMR) indicated the Medical Social Worker (MSW) did not submit or complete a psychosocial assessment since Patient 10s SOC of 11/19/2024. During a concurrent interview and record review on 1/7/2025 at 3:45 p.m., with the Director of Patient Care Services Designee (DD), Patient 10s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a psychosocial assessment by the MSW, and documentation should be submitted within 5 days of the SOC date. The DD stated the importance of completing a psychosocial assessment for the patients is to assess safety of their environment at home, see if there are any social issues within the family dynamic, and provide community resources if needed. 8. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). A review of Patient 12s Electronic Medical Record (EMR) indicated that since Patient 12s recertification date of 11/4/2024, the Spiritual Counselor (SC) did not submit or complete a spiritual assessment, and the Volunteer Coordinator (VC) did not submit or complete a volunteer assessment. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m., with the DD, Patient 12s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a spiritual assessment by SC, and a volunteer assessment by VC, and stated documentation should be submitted within 5 days of Patient 12s recertification date of 11/4/2024. The DD stated it is important for the SC to complete a spiritual assessment of the patient, as indicated in the recertification period, to check if there are any new spiritual and emotional needs of the patient and update the plan of care. The DD also stated it is important to provide the patient with volunteer services because the patient verbalized a need for it, and it is important for the VC to complete a volunteer assessment to identify the patients needs, like companionship, housekeeping, cooking, or errands. 9. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). A review of Patient 13s Electronic Medical Record (EMR) indicated that since Patient 13s recertification date of 10/31/2024, the MSW did not submit or complete a psychosocial assessment, the SC did not submit or complete a spiritual assessment, and the VC did not submit or complete a volunteer assessment. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m., with the DD, Patient 13s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a psychosocial assessment by MSW, spiritual assessment by SC, and a volunteer assessment by VC, and stated documentation should be submitted within 5 days of Patient 13s recertification date of 10/31/2024. The DD stated it is important for all disciplines of the team like MSW, SC and VC to complete their assessment upon Patient 13s recertification to reassess the patients needs, safety of the home, their emotional and spiritual needs as well as the family/caregiver. 4. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a record review of Patient 6s medical record form titled ";History of Psychosocial Assessment" undated, it indicated there were no entries made. During a concurrent interview and record review of Patient 6s medical records on 1/7/2024 at 2:14 PM with DD Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, assessments, visits notes, and physician's orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 6 on 12/12/2024. DD stated Patient 6 was receiving hospice services without a physicians admission order. DD stated Patient 6s ";Comprehensive Nursing Assessment" dated 12/12/2024 indicated MSW referral and a social worker visit was needed, but there was no documented evidence that the MSW conducted any psychosocial assessment for Patient 6. DD stated psychosocial assessments were important to assess the Patient 6s family dynamics, determine if Patient 6 has safety issues or concerns and/or need community resources. 5. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease (long-term heart problems due to high blood pressure) with heart failure. During a record review of Patient 7s medical record form titled ";History of Psychosocial Assessment" undated, indicated there were no entries made. During a concurrent interview and record review of Patient 7s medical records on 1/7/2024 at 2:14 PM with DD, Patient 7s ";Comprehensive Nursing Assessment," dated 11/26/2024, assessments, visit notes, and physicians orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 7 on 11/26/2024. DD stated Patient 7 was receiving hospice services without a physicians admission order. DD stated Patient 7s ";Comprehensive Nursing Assessment" dated 11/26/2024 indicated MSW referral and a social worker visit was needed, but there was no documented evidence that the MSW conducted any psychosocial assessment for Patient 7. DD stated psychosocial assessments were important to assess the Patient 7s family dynamics, determine if Patient 7 has safety issues or concerns and/or need community resources. 6. During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease that causes difficulty breathing). During a record review of Patient 8s medical record form titled ";History of Psychosocial Assessment" undated indicated there were no entries made. During a concurrent interview and record review of Patient 8s medical records on 1/7/2024 at 2:14 PM with DD, Patient 8s ";Comprehensive Nursing Assessment," dated 11/25/2024, assessments, visit notes, and physician's orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 8 on 11/25/2024. DD stated Patient 8 was receiving hospice services without a physicians admission order. DD stated Patient 8s ";Comprehensive Nursing Assessment" dated 11/25/2024 indicated MSW referral, but there was no documented evidence that the MSW conducted any psychosocial assessment for Patient 8. DD stated psychosocial assessments were important to assess the Patient 8s family dynamics, determine if Patient 8 has safety issues or concerns and/or need community resources. During an interview on 1/7/2025 at 12:04 p.m., with the Director of Patient Care Services Designee (DD), the DD stated a comprehensive interdisciplinary group meeting was to be done within two weeks of start of care. The DD stated the attendees included the Medical Director 1 (MD1), the Administrator (ADM), the Director of Patient Care Services (DPCS) and sometimes the Spiritual Counselor (SC) and the Medical Social Worker (MSW). The DD stated that the IDG meetings were open to other HA personnel. The DD stated during the IDG meetings each patients issues, medications, and symptoms were discussed. During an interview on 1/7/2025 at 12:04 p.m. with the DD, the DD stated patients Plan of Care (POC – an individualized care planned for each patient) are derived from the IDG meetings. The DD stated the admitting nurse initiates a patients POC, then the IDG follows up to collaborate within two weeks of start of care. The DD stated patients IDG meetings are done to address patients issues and problems and to organize interventions to reach goals. During an interview on 1/8/2025 at 10:50 a.m. with RN1, RN1 stated he has not been at the HA for the past two months. The RN1 stated he did not attend the last IDG meeting and when he does, he does not sign any document that verifies his attendance. The RN1 stated the IDG meetings are held every two weeks. The RN1 stated the DPCS formulates the patients POC. During an interview on 1/8/2025 at 11:41 a.m., with the ADM, the ADM stated the HAs IDG meetings are held every two weeks to discuss patients cases. The ADM stated patients POC are formulated and updated during the IDG meetings. The ADM stated the IDG members include the MD1, DPCS, and the visiting RN. During an interview on 1/8/2025 at 12:10 p.m., with the DPCS, the DPCS stated the HAs last IDG meeting was held on 12/11/2024. The DPCS stated the HA was to have an IDG meeting on 1/8/2025. The DPCS stated the HA has not had an IDG meeting due to the holidays. The DPCS stated IDG meetings are held on Wednesdays. The DPCS stated that if a patient was admitted after 12/11/2024, the patient has not had their IDG meeting because of the holidays. The DPCS stated patients cases are discussed during the IDG meetings. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a record review of Patient 1s medical record form titled ";Physician Order" dated 1/4/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 1s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Registered Nurse 1 (RN1)s narrative documentation included Patient 1s co-morbidities including diabetes (high blood sugar), arthritis (joint pain), scoliosis (abnormal spine curvature), and hypertension (high blood pressure). Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 1s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it electronically signed by the DPCS on 12/11/2024. During a record review of Patient 1s medical record form titled ";History of POC/IDG (interdisciplinary group)" undated, indicated there were no entries made. During a record review of Patient 1s electronic and physical medical record, did not indicate there was an interdisciplinary group comprehensive assessment conducted for Patient 1. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m., with the Director of Patient Care Services Designee (DD) of Patient 1s Electronic Medical Record (EMR) and physical medical record, the DD stated Patient 1s start of care date was 12/13/2024. The DD stated Patient 1 did not have a psychosocial assessment on file. The DD stated Patient 1 required a psychosocial assessment to determine if there were any family, safety, social, or mental issues at home. The DD stated the HA does not know if Patient 1 had a support system or if someone is taking care of him. The DD stated patients initial psychosocial assessment should be completed within a week of start of care. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m., with the DD of Patient 1s electronic and physical medical record, the DD stated she did not know if Patient 1 had an initial bereavement assessment which should have been completed by the Spiritual Counselor (SC) within a week of start of care. The DD stated the bereavement assessment was important to determine if the family or caregiver can benefit from grief support. The DD stated if the bereaved persons do not receive grief support, they might go through depression. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m., with the DD of Patient 1s electronic and physical medical record, the DD stated she did not find documentation or recalled if a comprehensive assessment with all the IDG member was held for Patient 1. The DD stated Patient 1s individualized POC was not completed because the IDG did not meet within five days of Patient 1s start of care. During an interview on 1/8/2025 at 7:57 a.m. with Patient 1, Patient 1 stated he was not receiving hospice services. Patient 1 stated he was not a hospice patient and that he wants ";to live a little bit longer". Patient 1 stated he is in the middle of changing primary physician. Patient 1 stated he has not heard of MD1 or MD2. Patient 1 stated he had never heard of RN1s name. During a concurrent interview and record review on 1/8/2025 at 12:10 p.m., with the DPCS of Patient 1s electronic and physical medical record, the DPCS stated RN1 provided Patient 1s initial home visit assessment on 12/13/2024 but signed it on 12/26/2024. The DPCS stated Patient 1s initial psychosocial and bereavement assessments were not done. The DPCS stated she did not know what Patient 1s allergies were because they were not listed on his medical record. The DPCS stated Patient 1 is receiving hospice services without a physician admission order. During a concurrent interview and record review on 1/8/2025 at 12:10 p.m., with the DPCS of Patient 1s electronic and physical medical record, the DPCS stated Patient 1s psychosocial and bereavement assessments were not done. The DPCS a bereavement assessment was important, to know if the family or the patient require spiritual services while receiving hospice care. During a concurrent interview and record review on 1/8/2025 at 12:10 p.m., with the DPCS of Patient 1s electronic and physical medical record, the DPCS stated she formulated Patient 1s POC based on the initial nursing assessment. The DPCS stated Patient 1s POC was not complete because the SC and MSW were not included. During a concurrent interview and record review on 1/8/2025 at 12:35 p.m., with the DPCS of Patient 1s EMR and physical medical record, the DPCS stated Patient 1 does not have any treatment orders. The DPCS stated it was important to have completed patient documents for liability reasons. The DPCS stated the HA did not have Patient 1s history and physical, or any documented evidence that supports the admitting nurses assessment. The DPCS stated there were no physical documents to attest to Patient 1s assessment. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). During a record review of Patient 2s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 2 was alert, oriented and able to verbalize pain. The form indicated RN1s narrative documentation included Patient 1s co-morbidities including diabetes, arthritis, depression, and open-heart surgery. RN1s documented narrative also included ";Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort." Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 2s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, functional limitations, activities permitted, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed. During a record review of Patient 2s medical record form titled ";History of POC/IDG" undated, indicated there were no entries made. During a record review of Patient 2s electronic and physical medical record, did not indicate there was an interdisciplinary group comprehensive assessment conducted for Patient 2. During a concurrent interview and record review on 1/7/2025 at 1 p.m., with the DD of Patient 2s EMR and physical medical record, the DD stated Patient 2s start of care date was 12/13/2024. The DD stated Patient 2 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 2s medical record did not have any documentation that he had an IDG comprehensive assessment. During a concurrent interview and record review on 1/7/2025 at 1 p.m., with the DD, the DD stated Patient 2 should have had an IDG meeting within five days of his start of care date to discuss and formulate a complete and appropriate POC. The DD stated Patient 2s individualized POC was not complete or signed. The DD stated a signature validates that she or he documented the POC. During a concurrent interview and record review on 1/7/2025 at 1 p.m., with the DD, the DD stated Patient 2 did not have a bereavement assessment. The DD stated Patient 2s bereavement assessment should have been completed by the SC within five days of start of care. The DD stated Patient 2s bereavement assessment was needed to be able to provide Patient 2s family with emotional and spiritual support. During an interview on 1/8/2025 at 8:12 a.m. with Patient 2, Patient 2 stated he was not dying, and that no one ever told him he was dying. Patient 2 stated he was referred by a friend of a friend, who also told him that he would get nutrition supplement and a blood sugar reading machine. Patient 2 stated he sees had a cardiologist and a primary doctor (MD3). Patient 2 stated I am not dying, only God knows when Ill die. During an interview on 1/8/2025 at 10:45 a.m. with License Vocational Nurse 1 (LVN1), LVN1 stated she visited Patient 2 twice. LVN1 stated she does not follow Patient 2s plan of care because she does not have it. LVN1 stated she checks Patient 2s blood pressure, ask when his last bowel movement was, if he is experiencing any medication side effects, if he had any falls, how his sleeping and appetite are, and if there are any changes to report. LVN1 stated Patient 2 can ambulate by himself but should use a walker. LVN1 stated Patient 2 can eat, transfer, and able to use restroom by himself. LVN1 stated Patient 2 will be seeing his primary physician either in March or April 2025. During an interview on 1/8/2025 at 11 a.m., with MD3, MD3 stated she was Patient 2s primary physician. MD3 stated she last saw Patient 2 on 11/14/2024. MD3 stated she did not refer Patient 2 for hospice services. MD3 stated Patient 2 has chronic illnesses but is a ";pretty healthy man". During a concurrent interview and record review on 1/8/2025 at 12:45 p.m., with the DPCS of Patient 2s electronic and physical medical record, the DPCS stated Patient 2s medical record did not indicate his diabetes was being assessed. The DPCS stated Patient 2 has a risk of going into diabetic ketoacidosis (a metabolic condition that occurs when there is a buildup of ketose in the blood which can be life threatening). The DPCS stated she completed Patient 2s POC but forgot to sign it. The DPCS stated her signature would indicate she documented the correct information. The DPCS stated Patient 2s POC was incomplete. The DPCS stated Patient 2s POC needs to be complete because it guides nurses with his patient care. 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. During a record review of Patient 3s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated RN1s narrative documentation included Patient 3s co-morbidities including diabetes, arthritis, gastritis (stomach pain) and osteoporosis (weak and brittle bones). Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 3s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed. During a record review of Patient 3s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a record review of Patient 3s medical record form titled ";History of Psychosocial Assessment" undated, indicated there were no entries made. During a record review of Patient 3s medical record form titled ";History of POC/IDG" undated, indicated there were no entries made. During a record review of Patient 3s electronic and physical medical record, indicated there was no psychosocial, bereavement, or IDG assessments documented. During a record review of Patient 3s Center for Medical and Medicare (CMS) form 807 (form used by a California Department of Public Health (CDPH) employee to document any interview, observation, or record review of a patient during a survey and/or investigation), Patient 3s CMS form 807 was completed by CDPH Employee 1 (CDPH1), CDPH1 documented she visited Patient 3 on 1/9/2025. CDPH1 documented Patient 3 did not know she was sick and did not know she required hospice services. CDPH1 documented Patient 3 stated License Vocational Nurse 1 (LVN1) visits every two weeks. CDPH1 documented Patient 3 has a primary physician (MD4) who she will see on 1/17/2025. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s electronic and physical medical record, the DD stated Patient 3s start of care date was 12/13/2024. The DD stated Patient 3s diabetes was not being assessed. The DD stated Patient 3s medical records did not contain her history and/or physical, therefore, the HA does not have any evidence to support Patient 3s documented LCD. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m., with the DD of Patient 3s electronic and physical medical record, the DD stated Patient 3 did not have an IDG comprehensive meeting assessment. The DD stated Patient 3s POC is not complete, therefore Patient 3 will not get the treatment ordered. The DD stated Patient 3s POC was not signed. The DD stated Patient 3s POC was a guide used by visiting nurses. The DD stated there could be miscommunication among providers on the patients care. During a concurrent interview and record review on 1/8/2025 at 1 p.m., with the DPCS of Patient 3s electronic and physical medical record, the DPCS stated RN1 provided Patient 3s initial home visit assessment on 12/13/2024. The DPCS stated Patient 3 is receiving hospice services without a physician admission or treatment orders. The DPCS stated Patient 3s medical record did not contain documented evidence to support RN1s documentation. The DPCS stated Patient 3 did not have psychosocial, bereavement or an IDG comprehensive assessments.

Based on interview and record review the Hospice Agency (HA) failed to ensure twelve of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) receive an initial bereavement assessment. This failure had the potential to result in placing the patients and their family/caregiver at risk of spiritual and emotional distress and their ability to cope with the patients' death. --- 8. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). A review of Patient 10s Electronic Medical Record (EMR) indicated that the Chaplain/Spiritual Counselor (SC) did not submit or complete an initial bereavement assessment for Patient 10 since the SOC date of 11/19/2024. During a concurrent interview and record review on 1/7/2025 at 3:45 p.m., with the Director of Patient Care Services Designee (DD), Patient 10s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete an initial bereavement assessment to assess the support needs of the patient, family or caregiver and assess the emotional and spiritual assistance they would need. 9. A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). A review of Patient 11s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 11 since the SOC date of 11/6/2024. During a concurrent interview and record review on 1/7/2025 at 4 p.m., with the DD, Patient 11s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to find out the emotional and spiritual needs of the patient and family/caregiver. 10. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). A review of Patient 12s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 12 since the SOC date of 8/6/2024. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m., with the DD, Patient 11s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to assess their emotional or spiritual needs, as well as the family/caregiver and provide support as needed. 11. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). A review of Patient 13s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 13 since the SOC date of 8/2/2024. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m., with the DD, Patient 13s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to know how the patient is coping, and what the patient and family/caregiver needs are, emotionally and spiritually. 12. A review of Patient 14s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 7/20/2023, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years), and an End of Care (EOC) date of 8/14/2023. A review of Patient 14s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 14 since the SOC date of 7/20/2023. During a concurrent interview and record review on 1/7/2025 at 4:33 p.m., with the DD, Patient 14s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to know and understand what the patient needs emotionally and spiritually to cope with their health, as well as know the family/caregiver needs. 5. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a record review of Patient 6s medical record form titled ";History of Bereavement Assessment" undated, it indicated there were no entries made. During a concurrent interview and record review of Patient 6s medical records on 1/7/2024 at 2:14 PM, with DD Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, assessments, visits notes, and physician's orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 6 on 12/12/2024. DD stated Patient 6 was receiving hospice services without a physicians admission order. DD stated there was no documented evidence that a bereavement assessment was conducted for Patient 6. DD stated it was important to conduct a bereavement assessment for Patient 6 to assess the emotional and spiritual needs of the family. 6. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease (long-term heart problems due to high blood pressure) with heart failure. During a record review of Patient 7s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a concurrent interview and record review of Patient 7s medical records on 1/7/2024 at 2:14 PM, with DD, Patient 7s ";Comprehensive Nursing Assessment," dated 11/26/2024, assessments, visit notes, and physician's orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 7 on 11/26/2024. DD stated Patient 7 was receiving hospice services without a physicians admission order. DD stated there was no documented evidence that a bereavement assessment was conducted for Patient 7. DD stated it was important to conduct a bereavement assessment for Patient 7 to assess the emotional and spiritual needs of the family. 7. During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease that causes difficulty breathing). During a record review of Patient 8s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a concurrent interview and record review of Patient 8s medical records on 1/7/2024 at 2:14 PM, with DD, Patient 8s ";Comprehensive Nursing Assessment," dated 11/25/2024, assessments, visit notes, and physician's orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 8 on 11/25/2024. DD stated Patient 8 was receiving hospice services without a physicians admission order. DD stated there was no documented evidence that a bereavement assessment was conducted for Patient 8. DD stated it was important to conduct a bereavement assessment for Patient 8 to assess the emotional and spiritual needs of the family. During an interview on 1/7/2025 at 12:04 p.m., with the Director of Patient Care Services Designee (DD), the DD stated the IDG attendees included the Medical Director 1 (MD1), the Administrator (ADM), the Director of Patient Care Services (DPCS) and sometimes the Spiritual Counselor (SC) and the Medical Social Worker (MSW). During an interview on 1/7/2025 at 12:04 p.m., with the DD, the DD stated the admitting nurse initiates a patients POC, then the IDG follows up to collaborate within two weeks of start of care. The DD stated patients IDG meetings are done to address patients issues and problems and to organize interventions to reach goals. During an interview on 1/8/2025 at 11:41 a.m., with the ADM, the ADM stated the HAs IDG meetings are held every two weeks to discuss patients cases. The ADM stated patients POC are formulated and updated during the IDG meetings. The ADM stated the IDG members include the MD1, DPCS, and the visiting RN. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a record review of Patient 1s medical record form titled ";Physician Order" dated 1/4/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 1s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 1 was referred to the Medical Social Worker (MSW) and the Spiritual Counselor (SC). Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 1s medical record form titled ";History of Bereavement Assessment" undated, did not indicate there were entries made. During a record review of Patient 1s electronic and physical medical record, did not indicate there was bereavement assessment conducted for Patient 1. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m., with the Director of Patient Care Services Designee (DD) of Patient 1s Electronic Medical Record (EMR) and physical medical record, the DD stated she did not know if Patient 1 had an initial bereavement assessment which should have been completed by the Spiritual Counselor (SC) within a week of start of care. The DD stated the bereavement assessment was important to determine if the family or caregiver can benefit from grief support. The DD stated if the bereaved persons do not receive grief support, they might go through depression. During a concurrent interview and record review on 1/8/2025 at 12:10 p.m., with the DPCS of Patient 1s electronic and physical medical record, the DPCS stated RN1 provided Patient 1s initial home visit assessment on 12/13/2024 but signed it on 12/26/2024. The DPCS stated Patient 1s initial bereavement assessment was not done. The DPCS stated a bereavement assessment was important, to know if the family or the patient required spiritual services while receiving hospice care. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). During a record review of Patient 2s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 2 was referred to the MSW, SC, and Volunteer. Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the DD of Patient 2s electronic and physical medical record, the DD stated Patient 2s start of care date was 12/13/2024. The DD stated Patient 2 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 2 did not have a bereavement assessment. The DD stated Patient 2s bereavement assessment should have been completed by the SC within five days of start of care. The DD stated Patient 2s bereavement assessment was needed to be able to provide Patient 2s family with emotional and spiritual support. 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. During a record review of Patient 3s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated under section ";Referrals", Patient 3 was referred to the MSW, SC, and Volunteer. Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 3s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a record review of Patient 3s electronic and physical medical record, indicated there was no bereavement assessment documented. During a concurrent interview and record review on 1/8/2025 at 1 p.m. with the DPCS of Patient 3s electronic and physical medical record, the DPCS stated RN1 provided Patient 3s initial home visit assessment on 12/13/2024. The DPCS stated Patient 3 is receiving hospice services without a physician admission or treatment orders. The DPCS stated Patient 3s medical record did not contain documented evidence to support RN1s documentation. The DPCS stated Patient 3 did not have a bereavement assessment. 4. During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 11/27/2024 and an end of care date of 12/12/2024, with a primary diagnosis of unspecified cirrhosis of the liver. During a record review of Patient 5s medical record form titled ";Physician Order" dated 12/11/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 5s medical record form titled ";Comprehensive Nursing Assessment" dated 11/27/2024, indicated under section ";Referrals", Patient 3 was referred to the MSW and SC. Lastly, the form indicated it was electronically signed by RN1 on 11/27/2024. During a record review of Patient 5s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a record review of Patient 5s electronic and physical medical record, indicated there was no bereavement assessment documented. During a concurrent interview and record review on 1/8/2025 at 1:10 p.m. with the DPCS of Patient 4s electronic and physical medical record, the DPCS Patient 5 did not have an initial bereavement assessment.

Based on observation, interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the individualized quality of care and support to patients and families) met and updated the comprehensive assessments at least every 15 days for seven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 10, Patient 11, Patient 12, and Patient 13). This failure resulted in patients progress toward desired outcomes, including the patient's response to care will not be identified, causing delay of treatment, intervention, and management of the needs of the terminally ill patients. --- During an interview on 1/7/2025 at 3:45pm with the Director of Patient Care Services Designee (DD), the DD stated the members of the Interdisciplinary Group (IDG) consist of the Medical Director, Director of Patient Care Services (DPCS), the Medical Social Worker (MSW), the Spiritual Counselor (SC), and the Registered Nurses (RN) and Licensed Vocational Nurses (LVN) if they are available. The DD stated IDG meetings are held every two weeks and alternate from face to face to via zoom. The DD further stated if the POC/IDG Review was not signed by a particular IDG member, it would mean that IDG member was not present during the meeting to review the patients individualized plan of care. 4. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). During a review of Patient 10s medical record form titled ";Comprehensive Nursing Assessment" dated 11/19/2024, indicated RN1s narrative documentation included Patient 10s co-morbidities including arthritis (joint pain), diabetes (high blood sugar), history of pancreatic cancer (cancer to the pancreas), post breast cancer, one kidney removal, Parkinsons tremors (a brain disorder that causes movement problems including tremors), history of heart attack, asthma (chronic lung disease that causes airways to narrow and swell, making it hard to breathe), history of depression (mental health condition that involves constant low mood and loss of interest) and schizophrenia (chronic mental illness that affects a persons thoughts, feelings and behaviors). The form indicated it was electronically signed by RN1 on 11/19/2024. During a concurrent interview and record review on 1/7/2025 at 3:45 pm, with the DD, Patient 10s medical record titled History of POC/IDG was reviewed. Patient 10s record indicated the following: - POC/IDG, Initial, dated 11/27/2024 with signatures of the Medical Director (MD) and DPCS, no signatures of the Medical Social Worker (MSW) and Spiritual Counselor (SC). - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and the DPCS, no signatures of the MSW and SC. The DD stated and confirmed Patient 10s POC/IDG dated 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated it is important to have a signature of all IDG members on the POC/IDG to validate their attendance in the meeting, and all members are aware of covering all the needs of the patient holistically. 5. A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). During a review of Patient 11s medical record form titled ";Comprehensive Nursing Assessment" dated 11/6/2024, indicated Patient The form indicated the SNs narrative documentation included Patient 11s co-morbidities including type 1 diabetes (high blood sugar), hypertension (high blood pressure), hyperlipidemia (high cholesterol). Lastly, the form indicated it was electronically signed by the SN on 11/6/2024. During a concurrent interview and record review on 1/7/2025 at 4 pm., with the DD, Patient 11s medical record titled History of POC/IDG was reviewed. Patient 11s record indicated the following: - POC/IDG, Initial, dated 11/13/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 11s POC/IDGs dated 11/13/2024, 11/27/2024, and 12/11/2924 were missing IDG member signatures and were incomplete. The DD stated it is important to have all members of the IDG present and sign the IDG to show their presence and provide coordination of care among all disciplines. 6. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). During a review of Patient 12s medical record form titled ";Re-Cert Assessment" dated 11/4/2024, indicated the DPCS narrative documentation included Patient 12s co-morbidities including hypertension (high blood pressure), benign prostatic hyperplasia (BPH, noncancerous enlargement of the prostate gland), and hyperlipidemia (high cholesterol). The form indicated it was electronically signed by the DPCS on 11/4/2024. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the DD, Patient 12s medical record titled History of POC/IDG was reviewed. Patient 12s record indicated the following: - POC/IDG, Initial, dated 8/7/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 8/21/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 9/4/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/18/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/2/2024 with signatures of the MD and the DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 10/16/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/30/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/13/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 12s POC/IDGs dated 9/4/2024, 9/18/2024, 10/2/2024, 10/16/2024, 10/30/2024, 11/13/2024, 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated the importance of all IDG members to be present, complete and sign the patients IDG is to be able to review the POC together, be on the same page about the patients care and update as needed. 7. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). During a review of Patient 13s medical record form titled ";Re-cert Assessment" dated 10/31/2024, indicated the DPCS documented narrative included Patient 13s co-morbidities including hypertension (high blood pressure), and arthritis (joint pain). The form indicated it was electronically signed by the DPCS on 10/31/2024. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m. with the D), Patient 13s medical record titled History of POC/IDG was reviewed. Patient 13s record indicated the following: - POC/IDG, Initial, dated 8/7/2024 with signatures of the MD, DPCS and MSW, no signature of the SC. - POC/IDG, Updated, dated 8/21/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/4/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/18/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/2/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/16/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/30/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/13/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 13s POC/IDGs dated 8/7/2024, 8/21/2024, 9/4/2024, 9/18/2024, 10/2/2024, 10/16/2024, 10/30/2024, 11/13/2024, 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated the importance of all members of the IDG keep up with the meetings, and complete and sign the POC/IDG is to make sure the patients needs, like safety, care, medications, emotional/spiritual, and eligibility are being updated. During an interview on 1/7/2025 at 12:04 p.m., with the Director of Patient Care Services Designee (DD), the DD stated the comprehensive interdisciplinary group meeting were held every two weeks. The DD stated the attendees included the Medical Director 1 (MD1), the Administrator (ADM), the Director of Patient Care Services (DPCS) and sometimes the Spiritual Counselor (SC) and the Medical Social Worker (MSW). The DD stated that the IDG meetings were open to other HA personnel. The DD stated during the IDG meetings each patients issues, medications, and symptoms were discussed. During an interview on 1/7/2025 at 12:04 p.m., with the DD, the DD stated patients Plan of Care (POC – an individualized care planned for each patient) are derived from the IDG meetings. The DD stated the admitting nurse initiates a patients POC, then the IDG follows up to collaborate. The DD stated patients IDG meetings are done to address patients issues and problems and to organize interventions to reach goals. During an interview on 1/8/2025 at 10:50 a.m., with RN1, RN1 stated he has not been at the HA for the past two months. The RN1 stated he did not attend the last IDG meeting. The RN1 stated the IDG meetings are held every two weeks. During an interview on 1/8/2025 at 11:41 a.m. with the ADM, the ADM stated the HAs IDG meetings are held every two weeks to discuss patients cases. The ADM stated patients POC are formulated and updated during the IDG meetings. The ADM stated the IDG members include the MD1, DPCS, and the visiting RN. During an interview on 1/8/2025 at 12:10 p.m. with the DPCS, the DPCS stated the HAs last IDG meeting was held on 12/11/2024. The DPCS stated the HA was to have an IDG meeting on 1/8/2025. The DPCS stated the HA has not had an IDG meeting due to the holidays. The DPCS stated IDG meetings are held on Wednesdays. The DPCS stated that if a patient was admitted after 12/11/2024, the patient has not had their IDG meeting because of the holidays. The DPCS stated patients cases are discussed during the IDG meetings. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a record review of Patient 1s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Registered Nurse 1 (RN1)s narrative documentation included Patient 1s co-morbidities including diabetes (high blood sugar), arthritis (joint pain), scoliosis (abnormal spine curvature), and hypertension (high blood pressure). Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 1s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it electronically signed by the DPCS on 12/11/2024. During a record review of Patient 1s medical record form titled ";History of POC/IDG (interdisciplinary group)" undated, indicated there were no entries made. During a record review of Patient 1s electronic and physical medical record, did not indicate there was any interdisciplinary group comprehensive assessment conducted for Patient 1. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m. with the DD of Patient 1s electronic and physical medical record, the DD stated she did not find documentation or recalled if a comprehensive assessment with all the IDG member was held for Patient 1. The DD stated Patient 1s individualized POC was not completed because the IDG did not meet within five days of Patient 1s start of care. During a concurrent interview and record review on 1/8/2025 at 12:10 p.m. with the DPCS stated Patient 1s POC was not complete because the SC and MSW were not included. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated RN1s narrative documentation included Patient 1s co-morbidities including diabetes, arthritis, depression, and open-heart surgery. RN1s documented narrative also included ";Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort." Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 2s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, functional limitations, activities permitted, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed. During a record review of Patient 2s medical record form titled ";History of POC/IDG" undated, indicated there were no entries made. During a record review of Patient 2s electronic and physical medical record, did not indicate there was an interdisciplinary group comprehensive assessment conducted for Patient 2. During a concurrent interview and record review on 1/7/2025 at 1 p.m., with the DD of Patient 2s EMR and physical medical record, the DD stated Patient 2s medical record did not have any documentation that he had an IDG comprehensive assessment. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the DD, the DD stated Patient 2 should have had an IDG meeting within five days of his start of care date to discuss and formulate a complete and appropriate POC. The DD stated Patient 2s individualized POC was not complete or signed. During a concurrent interview and record review on 1/8/2025 at 12:45 p.m. with the DPCS of Patient 2s electronic and physical medical record, the DPCS stated Patient 2s medical record did not indicate his diabetes was being assessed. The DPCS stated Patient 2 has a risk of going into diabetic ketoacidosis (a metabolic condition that occurs when there is a buildup of ketose in the blood which can be life threatening). The DPCS stated she completed Patient 2s POC but forgot to sign it. The DPCS stated her signature would indicate she documented the correct information. The DPCS stated Patient 2s POC was incomplete. The DPCS stated Patient 2s POC needs to be complete because it guides nurses with his patient care. 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated RN1s narrative documentation included Patient 3s co-morbidities including diabetes, arthritis, gastritis (stomach pain) and osteoporosis (weak and brittle bones). Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 3s medical record form titled ";History of POC/IDG" undated, indicated there were no entries made. During a record review of Patient 3s electronic and physical medical record, indicated there was no IDG assessment documented. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s electronic and physical medical record, the DD stated Patient 3s start of care date was 12/13/2024. The DD stated Patient 3s diabetes was not being assessed. The DD stated Patient 3s medical records did not contain her history and/or physical. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s electronic and physical medical record, the DD stated Patient 3 did not have an IDG comprehensive meeting assessment. The DD stated Patient 3s POC is not complete, therefore Patient 3 will not get the treatment ordered. The DD stated Patient 3s POC was not signed. The DD stated Patient 3s POC was a guide used by visiting nurses. The DD stated there could be miscommunication among providers on the patients care. During a concurrent interview and record review on 1/8/2025 at 1 p.m. with the DPCS of Patient 3s electronic and physical medical record, the DPCS stated RN1 provided Patient 3s initial home visit assessment on 12/13/2024. The DPCS stated Patient 3 did not have an IDG comprehensive assessment.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation regarding Care Planning and Coordination of Services for patients was met as follows: --- 1. The HA failed to ensure a social worker and a spiritual counselor attended their interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) to meet the psychosocial, emotional, and spiritual needs for twelve of 14 hospice sample patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L541). 2. The HA failed to ensure four of fourteen sampled patients (Patient 6, Patient 7, Patient 8, and Patient 10) Plan of Care (POC – individualized care planned) received services as indicated in the plan of care. (Refer to L543). 3. The HA failed to ensure an individualized plan of care (POC) was formulated for four of 14 sample patients (Patient 2, Patient 10, Patient 12, and Patient 13) to reflect their care. (Refer to L545). 4. The HA failed to ensure four of 14 sample patients (Patient 1, Patient 2, Patient 3, and Patient 5) had their treatment plan listed on their plan of care (POC) to meet their individual needs. (Refer to L549). 5. The HA failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) reviewed and revised eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13) plan of care (POC- an individualized care planned) every 15 days. (Refer to L552). 6. The HA failed to ensure four of fourteen sampled patients (Patient 6, Patient 7, Patient 8, and Patient 10) care and services were communicated with the hospice team to ensure services were provided as ordered. This failure resulted in HA staff putting patients at risk of harm by not being aware of patients status. (Refer to L554). The cumulative effect of these systemic practices resulted in the HA not providing the services/care as ordered and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life.

Based on interview and record review the Hospice Agency (HA) failed to ensure a social worker and a spiritual counselor attended their interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) to meet the psychosocial, emotional, and spiritual needs for 12 of 14 hospice sample patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in patients not being provided the care and services required and needed in their end-of-life process. --- 8. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). A review of Patient 10s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 10s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. The sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. A review of Patient 10s Electronic Medical Record (EMR) indicated that the Medical Social Worker (MSW) did not submit or complete a psychosocial assessment since Patient 10s SOC of 11/19/2024. During a concurrent interview and record review on 1/7/2025 at 3:45 p.m., with the Director of Patient Care Services Designee (DD), Patient 10s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a psychosocial assessment by the MSW, and documentation should be submitted within 5 days of the SOC date. The DD stated the importance of completing a psychosocial assessment for the patients is to assess safety of their environment at home, see if there are any social issues within the family dynamic, and provide community resources if needed. A review of Patient 10s Electronic Medical Record (EMR) indicated that the Chaplain/Spiritual Counselor (SC) did not submit or complete an initial bereavement assessment for Patient 10 since the SOC date of 11/19/2024. During a concurrent interview and record review on 1/7/2025 at 3:45 p.m. with the Director of Patient Care Services Designee (DD), Patient 10s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete an initial bereavement assessment to assess the support needs of the patient, family or caregiver and assess the emotional and spiritual assistance they would need. During a concurrent interview and record review on 1/7/2025 at 3:45 pm., with the DD, Patient 10s medical record titled History of POC/IDG was reviewed. Patient 10s record indicated the following: - POC/IDG, Initial, dated 11/27/2024 with signatures of the Medical Director (MD) and DPCS, no signatures of the Medical Social Worker (MSW) and Spiritual Counselor (SC). - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and the DPCS, no signatures of the MSW and SC. The DD stated and confirmed Patient 10s POC/IDG dated 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated it is important to have a signature of all IDG members on the POC/IDG to validate their attendance in the meeting, and all members are aware of covering all the needs of the patient holistically. 9. A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). A review of Patient 11s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 11s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. The sections allergies, diet, treatment, other, DME (durable medical equipment), and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. A review of Patient 11s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. A review of Patient 11s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 11 since the SOC date of 11/6/2024. During a concurrent interview and record review on 1/7/2025 at 4 p.m., with the DD, Patient 11s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to find out the emotional and spiritual needs of the patient and family/caregiver. During a concurrent interview and record review on 1/7/2025 at 4 pm, with the DD, Patient 11s medical record titled History of POC/IDG was reviewed. Patient 11s record indicated the following: - POC/IDG, Initial, dated 11/13/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 11s POC/IDGs dated 11/13/2024, 11/27/2024, and 12/11/2924 were missing IDG member signatures and were incomplete. The DD stated it is important to have all members of the IDG present and sign the IDG to show their presence and provide coordination of care amongst all disciplines. 10. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). A review of Patient 12s medical record form titled, ";Physician Order" undated, indicated there was no physician's admission order for hospice services. A review of Patient 12s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. The sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. A review of Patient 12s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 12 since the SOC date of 8/6/2024. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m., with the DD, Patient 11s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to assess their emotional or spiritual needs, as well as the family/caregiver and provide support as needed. A review of Patient 12s Electronic Medical Record (EMR) indicated that since Patient 12s recertification date of 11/4/2024, the Spiritual Counselor (SC) did not submit or complete a spiritual assessment, and the Volunteer Coordinator (VC) did not submit or complete a volunteer assessment. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the DD, Patient 12s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a spiritual assessment by SC, and a volunteer assessment by VC, and stated documentation should be submitted within 5 days of Patient 12s recertification date of 11/4/2024. The DD stated it is important for the SC to complete a spiritual assessment of the patient, as indicated in the recertification period, to check if there are any new spiritual and emotional needs of the patient and update the plan of care. The DD also stated it is important to provide the patient with volunteer services because the patient verbalized a need for it, and it is important for the VC to complete a volunteer assessment to identify the patients needs, like companionship, housekeeping, cooking, or errands. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the DD, Patient 12s medical record titled History of POC/IDG was reviewed. Patient 12s record indicated the following: - POC/IDG, Initial, dated 8/7/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 8/21/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 9/4/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/18/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/2/2024 with signatures of the MD and the DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 10/16/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/30/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/13/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 12s POC/IDGs dated 9/4/2024, 9/18/2024, 10/2/2024, 10/16/2024, 10/30/2024, 11/13/2024, 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated the importance of all IDG members to be present, complete and sign the patients IDG is to be able to review the POC together, be on the same page about the patients care and update as needed. 11. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). A review of Patient 13s medical record form titled, ";Physician Order" undated, indicated there was no physician's admission order for hospice services. A review of Patient 13s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. The sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. A review of Patient 13s Electronic Medical Record (EMR) indicated that since Patient 13s recertification date of 10/31/2024, the MSW did not submit or complete a psychosocial assessment, the SC did not submit or complete a spiritual assessment and the VC did not submit or complete a volunteer assessment. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m., with the DD, Patient 13s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a psychosocial assessment by MSW, spiritual assessment by SC, and a volunteer assessment by VC, and stated documentation should be submitted within 5 days of Patient 13s recertification date of 10/31/2024. The DD stated it is important for all disciplines of the team like MSW, SC and VC to complete their assessment upon Patient 13s recertification to reassess the patients needs, safety of the home, their emotional and spiritual needs as well as the family/caregiver. A review of Patient 13s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 13 since the SOC date of 8/2/2024. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m., with the DD, Patient 13s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to know how the patient is coping, and what the patient and family/caregiver needs are, emotionally and spiritually. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m., with the DD, Patient 13s medical record titled History of POC/IDG was reviewed. Patient 13s record indicated the following: - POC/IDG, Initial, dated 8/7/2024 with signatures of the MD, DPCS and MSW, no signature of the SC. - POC/IDG, Updated, dated 8/21/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/4/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/18/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/2/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/16/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/30/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/13/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 13s POC/IDGs dated 8/7/2024, 8/21/2024, 9/4/2024, 9/18/2024, 10/2/2024, 10/16/2024, 10/30/2024, 11/13/2024, 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated the importance of all members of the IDG keep up with the meetings, and complete and sign the POC/IDG is to make sure the patients needs, like safety, care, medications, emotional/spiritual, and eligibility are being updated. 12. A review of Patient 14s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 7/20/2023, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years), and an End of Care (EOC) date of 8/14/2023. A review of Patient 14s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 14 since the SOC date of 7/20/2023. During a concurrent interview and record review on 1/7/2025 at 4:33 p.m., with the DD, Patient 14s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to know and understand what the patient needs emotionally and spiritually to cope with their health, as well as know the family/caregiver needs. 5. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a record review of Patient 6s medical record form, titled ";Comprehensive Nursing Assessment," dated 12/12/2024, the ";Comprehensive Nursing Assessment" indicated Patient 6s comorbidities (coexisting health condition) included hyperthyroidism (overproduction of thyroid hormone), seizures, fractured skull and nerve damage history, and history of depression (mental health condition that involves persistent low mood and loss of interest in activities). During a record review of Patient 6s medical record form, titled ";Physicians Order," dated 1/4/2025, the ";Physicians Order" indicated the following medications: 1. Start Date 12/19/2024 - Abilify (medication to treat Schizophrenia [chronic mental illness affecting ones thoughts, feelings, and behaviors]) 10 milligrams (mg, unit of measurement of weight) tablet orally once a day. 2. Start Date 12/19/2024 - Cogentin (medication to treat Parkinsons disease [chronic brain disorder affecting muscle control, balance, and movement]) 1 mg orally three times a day. 3. Start Date 12/19/2024 - Carbidopa/Levodopa 25 mg-100 mg tablet (medication to treat Parkinsons disease) 2 tablets orally three times a day. 4. Start Date 12/19/2024 - Gabapentin (medication to treat nerve pain) 600 mg orally every 8 hours as needed. 5. Start Date 12/19/2024 - Levothyroxine Sodium (medication to treat thyroid problems) 25 micrograms (mcg, unit of measurement of weight) orally once a day 6. Start Date 12/19/2024 - Lithium Carbonate (medication to treat seizures) 450 mg Extended-Release tablet orally once a day at bedtime. During a record review of Patient 6s medical record form titled ";Physicians Order" dated 1/4/2025, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 6s medical record form, titled ";POC Summary" as of 1/7/2025 (unsigned), the ";POC Summary," it indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was not signed. During a record review of Patient 6s medical record form, titled ";History of Psychosocial Assessment" undated, it indicated there were no entries made. During a record review of Patient 6s medical record form titled ";History of Bereavement Assessment" undated, it indicated there were no entries made. During a record review of Patient 6s medical record form titled ";History of POC/IDG" undated, it indicated there were no entries made. During a concurrent interview and record review of Patient 6s medical records on 1/7/2024 at 2:14 PM, with DD Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, ";CTI," dated 12/13/2024, and physician's orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 6 on 12/12/2024. DD stated Patient was receiving hospice services without a physicians admission order. DD stated there was no documented evidence the IDG developed and implemented an individualized care plan for all of Patient 6s medical problems. DD stated it was important to develop and implement an individualized care plan for patients (in general) to identify the patient problems, goals, interventions, and desired outcomes when providing care and services. DD stated there was no documented MSW visit to conduct Patient 6s psychosocial assessment. DD stated MSW visit was important to assess Patient 6s family dynamics and determine if Patient 6 has some safety issues/concerns or need community resources. DD stated there was no documented evidence of bereavement assessment conducted for Patient 6. 6. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease (long-term heart problems due to high blood pressure) with heart failure. During a record review of Patient 7s medical record form, titled ";Physicians Order" dated 12/19/2024, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 7s medical record form, titled ";POC Summary" as of 1/7/2025, signed on 12/11/2024, the ";POC Summary" it indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was signed by the DPCS on 12/11/2024. During a record review of Patient 7s medical record form, titled ";History of Psychosocial Assessment" undated, it indicated there were no entries made. During a record review of Patient 7s medical record form titled ";History of Bereavement Assessment" undated, it indicated there were no entries made. During a record review of Patient 7s medical record form titled ";History of POC/IDG" undated, it indicated there were only 2 IDG meetings (11/27/2024 and 12/11/2024) conducted since SOC on 11/26/2024. During a concurrent interview and record review of Patient 7s medical records on 1/7/2024 at 2:14 PM with DD Patient 7s ";Comprehensive Nursing Assessment," ";CTI," and physicians orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 7 on 11/26/2024. DD stated Patient was receiving hospice services without a physicians admission order. DD stated there were no hospital records or clinical records prior to hospice admission on file for Patient 7. DD stated based on the outside referral form from a ";marketer" not employed by the HA, titled ";Patient Information," Patient 7 also had diabetes (chronic disease due to uncontrolled blood sugar levels), asthma (chronic lung disease causing airway inflammation and tightening), sleep apnea (sleep disorder), and severe forgetfulness. DD stated there was no documented evidence the IDG developed and implemented an individualized care plan for all of Patient 7s medical problems. DD stated it was important to develop and implement an individualized care plan for patients (in general) to identify the patient problems, goals, interventions, and desired outcomes when providing care and services. DD stated there was no documented MSW visit to conduct Patient 7s psychosocial assessment. DD stated MSW visit was important to assess Patient 7s family dynamics and determine if Patient 7 has some safety issues/concerns or need community resources. DD stated there was no documented evidence of bereavement assessment conducted for Patient 7. 7. During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease that causes difficulty breathing). During a review of Patient 8s medical record form, titled ";Comprehensive Nursing Assessment," dated 11/25/2024, the ";Comprehensive Nursing Assessment" indicated Patient 8 was on oxygen therapy at 2 liters per minute via nasal cannula (device that provides supplemental oxygen through the nose). During a review of Patient 8s medical record form, titled ";Physicians Orders," dated 12/11/2024, the ";Physicians Orders" indicated the following medications: 1. Start Date 12/11/2024 – Divalproex Sodium (antiseizure medication used for bipolar disorder [mental illness causing extreme mood swings, affecting ones energy, activity levels, and concentration]) 500 mg Extended-Release tablet orally once a day 2. Start Date 12/11/2024 – Quetiapine Fumarate (antipsychotic medication used for bipolar disorder) 50 mg tablet once a day at bedtime. 3. Start Date 12/11/2024 – Risperidone (antipsychotic medication used for bipolar disorder) 1 mg tablet twice a day. During a record review of Patient 8s medical record form, titled ";Physicians Order" dated 12/11/2024, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 8s medical record form, titled ";POC Summary" as of 1/7/2025, signed on 12/11/2024, the ";POC Summary," it indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was signed by the DPCS on 12/11/2024. During a record review of Patient 8s medical record form, titled ";History of Psychosocial Assessment" undated, it indicated there were no entries made. During a record review of Patient 8s medical record form titled ";History of Bereavement Assessment" undated, it indicated there were no entries made. During a record review of Patient 8s medical record form titled ";History of POC/IDG" undated, it indicated there were only 2 IDG meetings (11/27/2024 and 12/11/2024) conducted since SOC on 11/26/2024. During a concurrent interview and record review of Patient 8s medical records on 1/7/2024 at 2:14 PM with DD Patient 6s ";Comprehensive Nursing Assessment," ";CTI," and physicians orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 8 on 11/25/2024. DD stated Patient was receiving hospice services without a physicians admission order. DD stated there were no hospital records or clinical records prior to hospice admission on file for Patient 8. DD stated there was no documented evidence the IDG developed and implemented an individualized care plan was developed and implemented for Patient 8 regarding oxygen therapy and Bipolar disorder. DD stated it was important to develop and implement an individualized care plan for Patient 8 to identify the patient problems, goals, interventions, and desired outcomes when providing care and services. DD stated there was no documented MSW visit to conduct Patient 8s psychosocial assessment. DD stated MSW visit was important to assess Patient 8s family dynamics and determine if Patient 8 has some safety issues/concerns or need community resources. DD stated there was no documented evidence of bereavement assessment conducted for Patient 8. During an interview on 1/7/2025 at 12:04 p.m. with the Director of Patient Care Services Designee (DD), the DD stated a comprehensive interdisciplinary group meeting was to be done within two weeks of a patient start of care. The DD stated the attendees included the Medical Director 1 (MD1), the Administrator (ADM), the Director of Patient Care Services (DPCS) and sometimes the Spiritual Counselor (SC) and the Medical Social Worker (MSW). The DD stated that the IDG meetings were open to other HA personnel. The DD stated during the IDG meetings each patients issues, medications, and symptoms were discussed. During an interview on 1/7/2025 at 2:49 p.m. with the Medical Social Worker (MSW), the MSW stated he has five days to make patient contact once alerted by the HAs Electronic Medical Record (EMR) system. The MSW stated his duties included performing psychosocial patient assessment, provide resources if needed, and to provide support and counseling. The MSW stated he documents patients psychosocial evaluation after seeing the patient. The MSW was unable to log into the HAs EMR and could not provide specific patient information. During an interview on 1/7/2025 at 3:01 p.m. with the Spiritual counselor (SC), the SC stated his duties included assessing patients within five days of start of care then documenting in their EMR. The SC stated he was part of the HAs IDG and attends 99% of the time. The SC stated the IDG meetings are held twice a month. The SC stated sometimes he gets dismissed from the IDG meetings when there are no ";special questions" for him. During an interview on 1/8/2025 at 10:32 a.m. with License Vocational Nurse 1 (LVN1), LVN1 stated she does not attend IDG meetings. During an interview on 1/8/2025 at 10:50 a.m. with Registered Nurse 1 (RN1), RN1 stated he has not been at the HA for the past two months. The RN1 stated he did not attend the last IDG meeting and when he does, he does not sign any document that verifies his attendance. The RN1 stated the IDG meetings are held every two weeks. During an interview on 1/8/2025 at 11:41 a.m. with the Administrator (ADM), the ADM stated the HAs IDG meetings are held every two weeks to discuss patients cases. The ADM stated the IDG members include the Medical Director 1 (MD1), Director of Patient Care Services (DPCS), and the visiting RN. During an interview on 1/8/2025 at 12:10 p.m. with the DPCS, the DPCS stated the HAs last IDG meeting was held on 12/11/2024. The DPCS stated patients cases are discussed during the IDG meetings. During an interview on 1/10/2025 at 10 a.m. with the Medical Director 1 (MD1), MD1 stated he coordinates patients care during the IDG meetings held every two weeks. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a record review of Patient 1s medical record form titled ";Physician Order" dated 1/4/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 1s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it electronically signed by the DPCS on 12/11/2024. During a record review of Patient 1s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a record review of Patient 1s medical record form titled ";History of Psychosocial Assessment" undated, indicated there were no entries made. During a record review of Patient 1s medical record form titled ";History of POC/IDG" undated, indicated there were no entries made. During a record review of Patient 1s electronic and physical medical record, did not indicate there was an psychosocial, spiritual, or interdisciplinary group comprehensive assessments conducted for Patient 1. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m. with the Director of Patient Care Services Designee (DD) of Patient 1s Electronic Medical Record (EMR) and physical medical record, the DD stated Patient 1s start of care date was 12/13/2024. The DD stated Patient 1 did not have a psychosocial assessment on file. The DD stated Patient 1 requires a psychosocial assessment to determine if there were any family, safety, social, or mental issues at home. The DD stated the HA does not know if Patient 1 had a support system or if someone is taking care of him. The DD stated patients initial psychosocial assessment should be completed within a week of start of care. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m. with the DD of Patient 1s electronic and physical medical record, the DD stated she did not know if Patient 1 had an initial bereavement assessment which should have been completed by the Spiritual Counselor (SC) within a week of start of care. The DD stated the bereavement assessment was important to determine if the family or caregiver can benefit from grief support. The DD stated if the bereaved persons do not receive grief support, they might go through depression. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m. with the DD of Patient 1s electronic and physical medical record, the DD stated she did not find documentation or recalled if a comprehensive assessment with all the IDG member was held for Patient 1. The DD stated Patient 1s individualized POC was not completed because the IDG did not meet within five days of Patient 1s start of care. During a concurrent interview and record review on 1/8/2025 at 12:10 p.m. with the DPCS of Patient 1s electronic and physical medical record, the DPCS stated RN1 provided Patient 1s initial home visit assessment on 12/13/2024 but signed it on 12/26/2024. The DPCS stated Patient 1s initial psychosocial and bereavement assessments were not done. The DPCS stated Patient 1s POC was not complete because the SC and MSW were not included. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). During a record review of Patient 2s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 2 was alert, oriented and able to verbalize pain. The form indicated RN1s narrative documentation included Patient 1s co-morbidities including diabetes, arthritis, depression, and open-heart surgery. Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 2s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, functional limitations, activities permitted, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed. During a record review of Patient 2s medical record form titled ";History of POC/IDG" undated, indicated there were no entries made. During a record review of Patient 2s electronic and physical medical record, did not indicate there was an interdisciplinary group comprehensive assessment conducted for Patient 2. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the DD of Patient 2s EMR and physical medical record, the DD stated Patient 2s start of care date was 12/13/2024. The DD stated Patient 2 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 2s medical record did not have any documentation that he had an IDG comprehensive assessment. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the DD, the DD stated Patient 2 should have had an IDG meeting within five days of his start of care date to discuss and formulate a complete and appropriate POC. The DD stated Patient 2s individualized POC was not complete or signed. The DD stated a signature validates that she or he documented the POC. During a concurrent interview and record review on 1/8/2025 at 12:45 p.m. with the DPCS of Patient 2s electronic and physical medical record, the DPCS stated Patient 2s medical record did not indicate his diabetes was being assessed. The DPCS stated Patient 2 has a risk of going into diabetic ketoacidosis (a metabolic condition that occurs when there is a buildup of ketose in the blood which can be life threatening). The DPCS stated Patient 2s POC was incomplete. The DPCS stated Patient 2s POC needs to be complete because it guides nurses with his patient care. 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. During a record review of Patient 3s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated RN1s narrative documentation included Patient 3s co-morbidities including diabetes, arthritis, gastritis (stomach pain) and osteoporosis (weak and brittle bones). Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 3s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed. During a record review of Patient 3s medical record form titled ";History of Psychosocial Assessment" undated, indicated there were no entries made. During a record review of Patient 3s medical record form titled ";History of POC/IDG" undated, indicated there were no entries made. During a record review of Patient 3s electronic and physical medical record, indicated there was no psychosocial, or IDG assessments documented. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s electronic and physical medical record, the DD stated Patient 3s start of care date was 12/13/2024. The DD stated Patient 3s diabetes was not being assessed. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s electronic and physical medical record, the DD stated Patient 3 did not have an IDG comprehensive meeting assessment. The DD stated Patient 3s POC is not complete, therefore Patient 3 will not get the treatment ordered. The DD stated Patient 3s POC was not signed. The DD stated Patient 3s POC was a guide used by visiting nurses. The DD stated there could be miscommunication among providers on the patients care. During a concurrent interview and record review on 1/8/2025 at 1 p.m. with the DPCS of Patient 3s electronic and physical medical record, the DPCS stated RN1 provided Patient 3s initial home visit assessment on 12/13/2024. The DPCS stated Patient 3 is receiving hospice services without a physician admission or treatment orders. The DPCS stated Patient 3s medical record did not contain documented evidence to support RN1s documentation. The DPCS stated Patient 3 did not have psychosocial or an IDG comprehensive assessments. 4. During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 11/27/2024 and an end of care date of 12/12/2024 with a primary diagnosis of unspecified cirrhosis of the liver. During a record review of Patient 5s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 5s medical record form titled ";Comprehensive Nursing Assessment" dated 11/27/2024, indicated RN1s narrative documentation included Patient 5s co-morbidities including anemia (low iron level in the blood) and osteoporosis (brittle bones). Lastly, the form indicated it was electronically signed by RN1 on 11/27/2024. During a record review of Patient 5s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. During a record review of Patient 5s medical record form titled ";History of Psychosocial Assessment" undated, indicated there were no entries made. During a record review of Patient 5s medical record form titled ";History of POC/IDG" undated, indicated there was one entry made on 12/11/2024. During a record review of Patient 5s medical record form titled ";POC/IDG Review" dated 12/11/2024, indicated the Spiritual, psychosocial, and other/physician discussion sections were left blank. The form also indicated Patient 5 did not have any documented problems, interventions, goals, or status. Lastly, the form also indicated the MSW and the spiritual counselor signatures were missing. During a concurrent interview and record review on 1/7/2025 at 2:17 p.m. with Patient 5s daughter/caregiver, (CG2), CG2 stated Patient 5 was seen by RN1 once and no one else from the HA visited or called. During a concurrent interview and record review on 1/8/2025 at 1:10 p.m. with the DPCS of Patient 5s electronic and physical medical record, the DPCS stated Patient 5 did not have psychosocial assessment. The DPCS stated the HA conducted one IDG meeting for Patient 5 dated 12/11/2024. The DPCS stated the MSW and SC did not see Patient 5 therefore were unable to contribute to the IDG meeting discussion. The DPCS stated Patient 5s IDG meeting documentation is missing the MSW and SC signatures because they did not attend the meeting.

Based on observation, interview, and record review the Hospice Agency (HA) failed to ensure four of fourteen sampled patients (Patient 6, Patient 7, Patient 8, and Patient 10) Plan of Care (POC – individualized care planned) are furnished hospice services as indicated in the written plan of care. This failure had the potential to result in not meeting the palliative (providing relief from pain and other symptoms of serious illness) and comfort needs of the patients during the terminal stage of the illness. --- 10. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). A review of Patient 10s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. During a record review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 11/19/2024 to 2/16/2025, indicated ";Given her comorbidities and terminal diagnosis, she qualifies for hospice care to manage symptoms and provide comfort. Certification for hospice care is recommended based on her terminal condition and current functional status." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 11/19/2024. During a review of Patient 10s medical record form titled ";Comprehensive Nursing Assessment" dated 11/19/2024, indicated Registered Nurse 1s (RN1) narrative documentation included Patient 10s co-morbidities including arthritis (joint pain), diabetes (high blood sugar), history of pancreatic cancer (cancer to the pancreas), post breast cancer, one kidney removal, Parkinsons tremors (a brain disorder that causes movement problems including tremors), history of heart attack, asthma (chronic lung disease that causes airways to narrow and swell, making it hard to breathe), history of depression (mental health condition that involves constant low mood and loss of interest) and schizophrenia (chronic mental illness that affects a persons thoughts, feelings and behaviors). Lastly, the form indicated it was electronically signed by RN1 on 11/19/2024. During a concurrent interview and record review on 1/7/2025 at 3:45 pm with the DD, Patient 10s medical record titled History of POC/IDG was reviewed. Patient 10s record indicated the following: - POC/IDG, Initial, dated 11/27/2024 with signatures of the Medical Director (MD) and DPCS, no signatures of the Medical Social Worker (MSW) and Spiritual Counselor (SC), and frequency of visit for Skilled Nurse (SN) of one per week and one as needed (PRN) visit. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and the DPCS, no signatures of the MSW and SC, and frequency of visit for Skilled Nurse (SN) of one per week and one as needed (PRN) visit. During a phone interview on 1/8/2025 at 1:45pm with Patient 10s Caregiver (CG1), CG1 stated Patient 10 lives alone in an apartment and is alert and oriented to self and time and is forgetful. CG1 stated she has been caring for Patient 10 since 8/11/2022 and assists her with baths, cooking, cleaning the apartment, and medication administration. CG1 stated since she has been caring for the patient, she has only seen two staff members from the HA come three times to see the patient. CG1 stated the ADM came first to sign up the patient for services, then came again another time to bring Patient 10s medication, and a SN came once in December. During an interview on 1/10/2025 at 12:30pm with the Director of Patient Care Services (DPCS), the DPCS stated she based the patients care plans on the initial nursing assessment. During a concurrent interview and record review on 1/10/2025 at 12:40pm with the Director of Patient Care Services (DPCS), Patient 10s medical record titled History of Visit Notes, was reviewed. The DPCS stated and verified the last documented SN visit for Patient 10 was dated 12/26/2024 by Registered Nurse 1 (RN 1). The DPCS stated there is no documented evidence that Patient 10 was visited the week after 12/26/2024. The DPCS further stated if the SN visit was not documented then the nurse did not do the visit. During an interview on 1/10/2025 at 12:50pm with the DPCS, the DPCS stated submission of SN visit notes are to be within 24 to 48 hours after the visit date. The DPCS stated it is important to submit visit notes within 24 to 48 hours after the visit, because the nurse can forget what they observed on the patient, and it can be difficult to rely on written notes. The DPCS further stated documenting a visit note after 48 hours from the visit can cause the SN to miss a lot of information in their documentation and there would not be continuity of care of the patient between the SNs. During an interview on 1/10/2025 at 2:35pm with RN 1, RN 1 stated if a visit with a patient is scheduled and verified prior to the date, the nurse is to show up to the patients home and if the patient is not there or the nurse is unable to make it then a missed visit note is documented on the patients EMR under the visit notes section. RN 1 stated he did not visit Patient 10 the week after 12/26/2024 because he was sick and unable to make the appointment. The RN 1 further stated he informed the Administrator (ADM) that he was sick and unable to make the visit, and the ADM was going to staff another nurse for the visit. RN 1 also stated he did not make any documentation that he was unable to visit Patient 10, in the EMR. RN 1 stated he is visiting nurse for Patient 10 and has gone to visit her. During a review of the HAs Policy and Procedure (P&P) titled, Missed Visits, with a revised date of April 2019, indicated ";A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. The P&P further indicates if a missed visit is not scheduled the clinician will notify the IDG and supervisor of the missed visit with the reason and document it in the patients clinical records to include; patient name, date/ and type of visit, reason for missed visit, description of unmet needs, any other follow up needed, other person notified of the missed visit, and signature of staff member reporting the information. 6. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a record review of Patient 6s medical record form, titled ";Comprehensive Nursing Assessment," dated 12/12/2024, the ";Comprehensive Nursing Assessment" indicated Patient 6s comorbidities (coexisting health condition) included hyperthyroidism (overproduction of thyroid hormone), seizures, fractured skull and nerve damage history, and history of depression (mental health condition that involves persistent low mood and loss of interest in activities). During a record review of Patient 6s medical record form, titled ";Physicians Order," dated 1/4/2025, the ";Physicians Order" indicated the following medications: 1. Start Date 12/19/2024 - Abilify (medication to treat Schizophrenia [chronic mental illness affecting ones thoughts, feelings, and behaviors]) 10 milligrams (mg, unit of measurement of weight) tablet orally once a day. 2. Start Date 12/19/2024 - Cogentin (medication to treat Parkinsons disease [chronic brain disorder affecting muscle control, balance, and movement]) 1 mg orally three times a day. 3. Start Date 12/19/2024 - Carbidopa/Levodopa 25 mg-100 mg tablet (medication to treat Parkinsons disease) 2 tablets orally three times a day. 4. Start Date 12/19/2024 - Gabapentin (medication to treat nerve pain) 600 mg orally every 8 hours as needed. 5. Start Date 12/19/2024 - Levothyroxine Sodium (medication to treat thyroid problems) 25 microgram (mcg, unit of measurement of weight) orally once a day 6. Start Date 12/19/2024 - Lithium Carbonate (medication to treat seizures) 450 mg Extended-Release tablet orally once a day at bedtime. During a record review of Patient 6s medical record form titled ";Physicians Order" dated 1/4/2025, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 6s medical record form, titled ";POC Summary" as of 1/7/2025 (unsigned), the ";POC Summary," it indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was not signed. During a record review of Patient 6s medical record form, titled ";History of Psychosocial Assessment" undated, it indicated there were no entries made. During a record review of Patient 6s medical record form titled ";History of Bereavement Assessment" undated, it indicated there were no entries made. During a record review of Patient 6s medical record form titled ";History of POC/IDG" undated, it indicated there were no entries made. During a concurrent interview and record review of Patient 6s medical records on 1/7/2024 at 2:14 PM with DD Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, ";CTI," dated 12/13/2024, and physicians orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 6 on 12/12/2024. DD stated Patient was receiving hospice services without a physicians admission order. DD stated there was no documented evidence the IDG developed and implemented an individualized care plan for all of Patient 6s medical problems. DD stated it was important to develop and implement an individualized care plan for patients (in general) to identify the patient problems, goals, interventions, and desired outcomes when providing care and services. DD stated there was no documented MSW visit to conduct Patient 6s psychosocial assessment. DD stated MSW visit was important to assess Patient 6s family dynamics and determine if Patient 6 has some safety issues/concerns or need community resources. DD stated there was no documented evidence of bereavement assessment conducted for Patient 6. 7. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease (long-term heart problems due to high blood pressure) with heart failure. During a record review of Patient 7s medical record form, titled ";Physicians Order" dated 12/19/2024, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 7s medical record form, titled ";POC Summary" as of 1/7/2025, signed on 12/11/2024, the ";POC Summary" it indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was signed by the DPCS on 12/11/2024. During a record review of Patient 7s medical record form, titled ";History of Psychosocial Assessment" undated, it indicated there were no entries made. During a record review of Patient 7s medical record form titled ";History of Bereavement Assessment" undated, it indicated there were no entries made. During a record review of Patient 7s medical record form titled ";History of POC/IDG" undated, it indicated there were only 2 IDG meetings (11/27/2024 and 12/11/2024) conducted since SOC on 11/26/2024. During a concurrent interview and record review of Patient 7s medical records on 1/7/2024 at 2:14 PM with DD Patient 6s ";Comprehensive Nursing Assessment," ";CTI," and physicians orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 7 on 11/26/2024. DD stated Patient was receiving hospice services without a physicians admission order. DD stated there were no hospital records or clinical records prior to hospice admission on file for Patient 7. DD stated based on the outside referral form from a ";marketer" not employed by the HA, titled ";Patient Information," Patient 7 also had diabetes (chronic disease due to uncontrolled blood sugar levels), asthma (chronic lung disease causing airway inflammation and tightening), sleep apnea (sleep disorder), and severe forgetfulness. DD stated there was no documented evidence the IDG developed and implemented an individualized care plan for all of Patient 7s medical problems. DD stated it was important to develop and implement an individualized care plan for patients (in general) to identify the patient problems, goals, interventions, and desired outcomes when providing care and services. DD stated there was no documented MSW visit to conduct Patient 7s psychosocial assessment. DD stated MSW visit was important to assess Patient 7s family dynamics and determine if Patient 7 has some safety issues/concerns or need community resources. DD stated there was no documented evidence of bereavement assessment conducted for Patient 7. 8. During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease that causes difficulty breathing). During a review of Patient 8s medical record form, titled ";Comprehensive Nursing Assessment," dated 11/25/2024, the ";Comprehensive Nursing Assessment" indicated Patient 8 was on oxygen therapy at 2 liters per minute via nasal cannula (device that provides supplemental oxygen through the nose). During a review of Patient 8s medical record form, titled ";Physicians Orders," dated 12/11/2024, the ";Physicians Orders" indicated the following medications: 1. Start Date 12/11/2024 – Divalproex Sodium (antiseizure medication used for bipolar disorder [mental illness causing extreme mood swings, affecting ones energy, activity levels, and concentration]) 500 mg Extended-Release tablet orally once a day 2. Start Date 12/11/2024 – Quetiapine Fumarate (antipsychotic medication used for bipolar disorder) 50 mg tablet once a day at bedtime. 3. Start Date 12/11/2024 – Risperidone (antipsychotic medication used for bipolar disorder) 1 mg tablet twice a day. During a record review of Patient 8s medical record form, titled ";Physicians Order" dated 12/11/2024, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 8s medical record form, titled ";POC Summary" as of 1/7/2025, signed on 12/11/2024, the ";POC Summary," it indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was signed by the DPCS on 12/11/2024. During a record review of Patient 8s medical record form, titled ";History of Psychosocial Assessment" undated, it indicated there were no entries made. During a record review of Patient 8s medical record form titled ";History of Bereavement Assessment" undated, it indicated there were no entries made. During a record review of Patient 8s medical record form titled ";History of POC/IDG" undated, it indicated there were only 2 IDG meetings (11/27/2024 and 12/11/2024) conducted since SOC on 11/26/2024. During a concurrent interview and record review of Patient 8s medical records on 1/7/2024 at 2:14 PM with DD Patient 6s ";Comprehensive Nursing Assessment," ";CTI," and physicians orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 8 on 11/25/2024. DD stated Patient was receiving hospice services without a physicians admission order. DD stated there were no hospital records or clinical records prior to hospice admission on file for Patient 8. DD stated there was no documented evidence the IDG developed and implemented an individualized care plan was developed and implemented for Patient 8 regarding oxygen therapy and Bipolar disorder. DD stated it was important to develop and implement an individualized care plan for Patient 8 to identify the patient problems, goals, interventions, and desired outcomes when providing care and services. DD stated there was no documented MSW visit to conduct Patient 8s psychosocial assessment. DD stated MSW visit was important to assess Patient 8s family dynamics and determine if Patient 8 has some safety issues/concerns or need community resources. DD stated there was no documented evidence of bereavement assessment conducted for Patient 8.

Based on interview and record review the Hospice Agency (HA) failed to ensure an individualized plan of care (POC) was formulated for four of 14 sample patients (Patient 2, Patient 10, Patient 12, and Patient 13) to reflect the care in the management of terminal illness and related conditions. This failure resulted in patients not receiving their individualized treatments needed for their care. It also had the potential to cause confusion to HA visiting staff, the patient, and their family/caregiver. --- 2. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). A review of Patient 10s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. During a review of Patient 10s medical record titled History of POC/IDG dated 11/27/2024 and 12/11/2024 indicated frequency of visits for Skilled Nurse (SN) of one per week and one as needed (PRN) visit. During a review of Patient 10s medical record form titled ";Comprehensive Nursing Assessment" dated 11/19/2024, indicated Patient 10s co-morbidities including arthritis (joint pain), diabetes (high blood sugar), history of pancreatic cancer (cancer to the pancreas), post breast cancer, one kidney removal, Parkinsons tremors (a brain disorder that causes movement problems including tremors), history of heart attack, asthma (chronic lung disease that causes airways to narrow and swell, making it hard to breathe), history of depression (mental health condition that involves constant low mood and loss of interest) and schizophrenia (chronic mental illness that affects a persons thoughts, feelings and behaviors). Lastly, the form indicated it was electronically signed by RN1 on 11/19/2024. During a concurrent interview and record review on 1/10/2025 at 12:33pm with the DPCS, Patient 10s POC/IDG Review dated 11/27/2024 and 12/11/2024 were reviewed. The DPCS stated and verified that the POC/IDGs dated 11/27/2024 and 12/11/2024 were not complete and did not include Patient 10s comorbidities. The DPCS stated if the patients comorbidities are not care planned the patient will not receive a holistic type of care and can decline faster. 3. A review of Patient 12s medical record form title\d ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). A review of Patient 12s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. During a review of Patient 10s medical record titled History of POC/IDG dated 12/11/2024 indicated frequency of visits for Skilled Nurse (SN) of one per week and one as needed (PRN) visit. During a review of Patient 12s medical record form titled ";Re-Cert Assessment" dated 11/4/2024, indicated the DPCS narrative documentation included Patient 12s co-morbidities including hypertension (high blood pressure), benign prostatic hyperplasia (BPH, noncancerous enlargement of the prostate gland), and hyperlipidemia (high cholesterol). Lastly, the form indicated it was electronically signed by the DPCS on 11/4/2024. During a concurrent interview and record review on 1/10/2025 at 12:33pm with the DPCS, Patient 12s POC/IDG Review dated 12/11/2024 was reviewed. The DPCS stated and verified that the POC/IDG dated 12/11/2024 was not complete and did not include Patient 12s comorbidities. The DPCS stated if the patients comorbidities are not care planned the patient will not receive a holistic type of care and can decline faster. 4. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). A review of Patient 13s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. During a review of Patient 13s medical record titled History of POC/IDG dated 12/11/2024 indicated frequency of visits for Skilled Nurse (SN) of one per week and one as needed (PRN) visit. During a review of Patient 13s medical record form titled ";Re-cert Assessment" dated 10/31/2024, indicated the DPCSs narrative documentation included Patient 13s co-morbidities including hypertension (high blood pressure), and arthritis (joint pain). Lastly, the form indicated it was electronically signed by the DPCS on 10/31/2024. During a concurrent interview and record review on 1/10/2025 at 12:33pm with the DPCS, Patient 13s POC/IDG Review dated 12/11/2024 was reviewed. The DPCS stated and verified that the POC/IDG was not complete and did not include Patient 13s comorbidities. The DPCS stated if the patients comorbidities are not care planned the patient will not receive a holistic type of care and can decline faster. 1. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). During a record review of Patient 2s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 2 was alert, oriented and able to verbalize pain. The form indicated Registered Nurse 1 (RN1)s narrative documentation included Patient 1s co-morbidities including diabetes, arthritis, depression, and open-heart surgery. RN1s documented narrative also included ";Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort." Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 2s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, functional limitations, activities permitted, diet, treatment, other, durable medical equipment (DME), supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed. During a record review of Patient 2s electronic and physical medical record, did not indicate there was an interdisciplinary group comprehensive assessment conducted for Patient 2. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the Director of Patient Care Services Designee (DD) of Patient 2s electronic medical record (EMR) and physical medical record, the DD stated Patient 2s start of care date was 12/13/2024. The DD stated Patient 2 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 2s medical record did not have any documentation that he had an interdisciplinary group (IDG) comprehensive assessment. The DD stated Patient 2 should have had an IDG meeting within five days of his start of care date to discuss and formulate a complete and appropriate POC. The DD stated Patient 2s individualized POC was not complete or signed. The DD stated a signature validates that she or he documented the POC. During a concurrent interview and record review on 1/8/2025 at 12:45 p.m. with the Director of Patient Care Services (DPCS) of Patient 2s electronic and physical medical record, the DPCS stated Patient 2s medical record did not indicate his diabetes was being assessed. The DPCS stated Patient 2 has a risk of going into diabetic ketoacidosis (a metabolic condition that occurs when there is a buildup of ketose in the blood which can be life threatening). The DPCS stated she completed Patient 2s POC but forgot to sign it. The DPCS stated her signature would indicate she documented the correct information. The DPCS stated Patient 2s POC was incomplete. The DPCS stated Patient 2s POC needs to be complete because it guides nurses with his patient care.

Based on interview and record review the Hospice Agency (HA) failed to ensure four of 14 sample patients (Patient 1, Patient 2, Patient 3, and Patient 5) had their treatment plan listed on their plan of care (POC) to meet their individual hospice needs. These failures resulted in patients care and services are not being performed in accordance with their plans of care. --- During an interview on 1/7/2025 at 12:04 p.m. with the Director of Patient Care Services Designee (DD), the DD stated a comprehensive interdisciplinary group meeting was to be done within two weeks of a patient start of care. The DD stated during the interdisciplinary group (IDG) meetings each patients issues, medications, and symptoms were discussed. During an interview on 1/8/2025 at 11:41 a.m. with the Administrator (ADM), the ADM stated the HAs IDG meetings are held every two weeks to discuss patients cases. The ADM stated the IDG members include the Medical Director 1 (MD1), Director of Patient Care Services (DPCS), and the visiting Registered Nurse (RN). During an interview on 1/8/2025 at 12:10 p.m. with the DPCS, the DPCS stated the HAs last IDG meeting was held on 12/11/2024. The DPCS stated patients cases are discussed during the IDG meetings. During an interview on 1/8/2025 at 1:10 p.m. with the DPCS, the DPCS stated that all the current HA patients POC were not complete because she ";had no idea" how to complete them. The DPCS stated she based the patients treatments on the admitting nurses documentation. The DPCS stated none of the current patients had treatment orders. During an interview on 1/10/2025 at 10 a.m. with the Medical Director 1 (MD1), MD1 stated he coordinates patients care during the IDG meetings held every two weeks. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a record review of Patient 1s medical record form titled ";Physician Order" dated 1/4/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 1s medical record form titled ";LCD Hospice Eligibility Determination" dated 12/13/2024, indicated Patient 1s qualifying factors included 1. Poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. 2. Increased visit to the emergency room. 3. Oxygen saturation less than or equal to 88% determined either by arterial blood gases or oxygen saturation monitors (these values may be obtained from recent hospital records) and 4. Unintentional progressive weight loss > or = 10% of body weight over last six months. During a record review of Patient 1s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 1s oxygen saturation was at 96%, but it does not indicate if his oxygen reading was with the use of oxygen or not. The form did not indicate who Patient 1s caregiver was or if he had any allergies to food or medication. The form indicated Registered Nurse 1 (RN1)s narrative documentation included Patient 1s co-morbidities including diabetes (high blood sugar), arthritis (joint pain), scoliosis (abnormal spine curvature), and hypertension (high blood pressure). Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 1s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, durable medical equipment (DME), supplies, and lab were left blank. The form also indicated it electronically signed by the DPCS on 12/11/2024. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m. with the Director of Patient Care Services Designee (DD) of Patient 1s Electronic Medical Record (EMR) and physical medical record, the DD stated Patient 1s start of care date was 12/13/2024. The DD stated Patient 1 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 1 was receiving oxygen from the HA without a physicians order. The DD stated Patient 1s diabetes was not being assessed by the HA. The DD stated she did not know if the family was managing Patient 1s diabetes. The DD stated Patient 1 can experience confusion, coma, or death if his blood sugar goes too high or too low. The DD stated diabetes complications can be prevented if managed correctly. The DD stated Patient 1s medical records did not contain his history and/or physical, therefore, the HA does not have any evidence to support Patient 1s documented LCD. During an interview on 1/8/2025 at 10:50 a.m. with RN1, RN1 stated he conducted Patient 1s initial assessment on 12/13/2025 and has seen Patient 1 for two or three visits. RN1 stated requesting Patient 1s medical records from his primary physician, Patient 1 and from the HAs Administrator (ADM) and DPCS. RN1 stated he reviews patients medications and if they have medications for diabetes, he asks about it. RN1 stated Patient 1 ";probably" told him what his blood sugar reading was, but RN1 did not document that. RN1 stated Patient 1 informed RN1 that his big problem was his breathing. RN1 stated he spoke with MD2 about Patient 1 at which time he received verbal orders from MD2. RN1 was unable to provide MD2s phone number. During a concurrent interview and record review on 1/8/2025 at 12:10 p.m. with the DPCS of Patient 1s EMR and physical medical record, the DPCS stated RN1 provided Patient 1s initial home visit assessment on 12/13/2024 but signed it on 12/26/2024. The DPCS stated Patient 1s initial psychosocial and bereavement assessments were not done. The DPCS stated she did not know what Patient 1s allergies were because they were not listed on his medical record. The DPCS stated Patient 1 is receiving hospice services without a physician admission order. During a concurrent interview and record review on 1/8/2025 at 12:35 p.m. with the DPCS of Patient 1s EMR and physical medical record, the DPCS stated Patient 1 does not have any treatment orders. The DPCS stated it was important to have completed patient documents for liability reasons. The DPCS stated the HA did not have Patient 1s history and physical, or any documented evidence that supports the admitting nurses assessment. The DPCS stated there were no physical documents to attest to Patient 1s assessment. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). During a record review of Patient 2s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 2s medical record form titled ";LCD Hospice Eligibility Determination" dated 12/13/2024, indicated Patient 2s qualifying factors included 1. Is patient optimally treated for heart disease with diuretics and vasodilators. 2. Does this CHF or angina patient meet the criteria for New York Heart Association (NYHA – a system for categorizing the severity of heart failure based on a patients physical activity limitations) Class IV (unable to carry out any physical activity without discomfort) level. During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 2 was alert, oriented and able to verbalize pain. The form also indicated Patient 2 required moderate assistance with ambulation, toileting, dressing, feeding, and bathing and was complete dependent when transferring. The form also indicted under the Cardiovascular section that Patient 2 had a regular pulse rate, and had +1 pitting level edema, but it does not state where the pitting edema was located. Section ";cardiac-related pain" under Cardiovascular was left blank. The form indicated RN1s narrative documentation included Patient 1s co-morbidities including diabetes, arthritis, depression, and open-heart surgery. RN1s documented narrative also included ";Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort." Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 2s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, functional limitations, activities permitted, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed. During a record review of Patient 2s medical record form titled ";History of POC/IDG" undated, indicated there were no entries made. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the DD of Patient 2s EMR and physical medical record, the DD stated Patient 2s start of care date was 12/13/2024. The DD stated Patient 2 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 2s medical record did not have any documentation that he had an IDG comprehensive assessment. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the DD, the DD stated Patient 2 should have had an IDG meeting within five days of his start of care date to discuss and formulate a complete and appropriate POC. The DD stated Patient 2s individualized POC was not complete or signed. The DD stated a signature validates that she or he documented the POC. During a concurrent interview and record review on 1/8/2025 at 12:45 p.m. with the DPCS of Patient 2s electronic and physical medical record, the DPCS stated Patient 2s medical record did not indicate his diabetes was being assessed. The DPCS stated Patient 2 has a risk of going into diabetic ketoacidosis (a metabolic condition that occurs when there is a buildup of ketose in the blood which can be life threatening). The DPCS stated Patient 2s POC was incomplete. The DPCS stated Patient 2s POC needs to be complete because it guides nurses with his patient care. 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. During a record review of Patient 3s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 3s medical record form titled ";LCD Hospice Eligibility Determination" dated 12/13/2024, indicated Patient 3s qualifying factors included 1. Poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. 2. Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, less than 30% of predicted. 3. Increased visit to the emergency room and 4. Oxygen saturation less than or equal to 88% determined either by arterial blood gases or oxygen saturation monitors (these values may be obtained from recent hospital records). During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 3 was not receiving oxygen. The form also indicated Patient 3 required moderate assistance with toileting, dressing, feeding, and bathing and was complete dependent when transferring and ambulating. The form also indicated under the Cardiovascular section that Patient 3 had +2 pitting level edema, but it does not state where the pitting edema was located. The form indicated RN1s narrative documentation included Patient 3s co-morbidities including diabetes, arthritis, gastritis (stomach pain) and osteoporosis (weak and brittle bones). RN1s documented narrative also included ";The patients current condition, medication, and treatments have been recorded and reviewed with MD via telephone and ordered to continue the medications and treatments upon admission." Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 3s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s electronic and physical medical record, the DD stated Patient 3 was not receiving oxygen from the HA. The DD stated Patient 3s diabetes was not being assessed. The DD stated Patient 3 did not have an IDG comprehensive meeting assessment. The DD stated Patient 3s POC is not complete, therefore Patient 3 will not get the treatment ordered. The DD stated Patient 3s POC was not signed. The DD stated Patient 3s POC was a guide used by visiting nurses. The DD stated there could be miscommunication among providers on the patients care. During a concurrent interview and record review on 1/8/2025 at 1 p.m. with the DPCS of Patient 3s electronic and physical medical record, the DPCS stated RN1 provided Patient 3s initial home visit assessment on 12/13/2024. The DPCS stated Patient 3 is receiving hospice services without a physician admission or treatment orders. 4. During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 11/27/2024 and an end of care date of 12/12/2024 with a primary diagnosis of unspecified cirrhosis of the liver. During a record review of Patient 5s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 5s medical record form titled ";Comprehensive Nursing Assessment" dated 11/27/2024, indicated RN1s narrative documentation included Patient 5s co-morbidities including anemia (low iron level in the blood) and osteoporosis (brittle bones). Lastly, the form indicated it was electronically signed by RN1 on 11/27/2024. During a record review of Patient 5s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. During a record review of Patient 5s medical record form titled ";POC/IDG Review" dated 12/11/2024, indicated the Spiritual, psychosocial, and other/physician discussion sections were left blank. The form also indicated Patient 5 did not have any documented problems, interventions, goals, or status. Lastly, the form also indicated the MSW, and the spiritual counselor signatures were missing. During a concurrent interview and record review on 1/7/2025 at 2:17 p.m. with Patient 5s daughter/caregiver, (CG2), CG2 stated Patient 5 was seen by RN1 once and no one else from the HA visited or called.

Based on interview and record review the Hospice Agency (HA) failed to ensure the interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, Medical Social Worker {MSW}, Chaplain, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) reviewed and revised eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13) plan of care (POC- an individualized care planned) every 15 days. This failure resulted in patients progress or decline will not be coordinated to the IDG members in order to update the information in the POC for further intervention or palliation (reducing something unpleasant, relief, alleviation) to manage the terminal illness. --- 8. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). A review of Patient 10s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 10s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. The sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. A review of Patient 10s Electronic Medical Record (EMR) indicated that the Medical Social Worker (MSW) did not submit or complete a psychosocial assessment since Patient 10s SOC of 11/19/2024. During a concurrent interview and record review on 1/7/2025 at 3:45 p.m. with the Director of Patient Care Services Designee (DD), Patient 10s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a psychosocial assessment by the MSW, and documentation should be submitted within 5 days of the SOC date. The DD stated the importance of completing a psychosocial assessment for the patients is to assess safety of their environment at home, see if there are any social issues within the family dynamic, and provide community resources if needed. A review of Patient 10s Electronic Medical Record (EMR) indicated that the Chaplain/Spiritual Counselor (SC) did not submit or complete an initial bereavement assessment for Patient 10 since the SOC date of 11/19/2024. During a concurrent interview and record review on 1/7/2025 at 3:45 p.m., with the Director of Patient Care Services Designee (DD), Patient 10s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete an initial bereavement assessment to assess the support needs of the patient, family or caregiver and assess the emotional and spiritual assistance they would need. During a concurrent interview and record review on 1/7/2025 at 3:45 pm., with the DD, Patient 10s medical record titled History of POC/IDG was reviewed. Patient 10s record indicated the following: - POC/IDG, Initial, dated 11/27/2024 with signatures of the Medical Director (MD) and DPCS, no signatures of the Medical Social Worker (MSW) and Spiritual Counselor (SC). - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and the DPCS, no signatures of the MSW and SC. The DD stated and confirmed Patient 10s POC/IDG dated 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated it is important to have a signature of all IDG members on the POC/IDG to validate their attendance in the meeting, and all members are aware of covering all the needs of the patient holistically. 9. A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). A review of Patient 11s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 11s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. The sections allergies, diet, treatment, other, DME (durable medical equipment), and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. A review of Patient 11s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. A review of Patient 11s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 11 since the SOC date of 11/6/2024. During a concurrent interview and record review on 1/7/2025 at 4:00 p.m. with the DD, Patient 11s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to find out the emotional and spiritual needs of the patient and family/caregiver. During a concurrent interview and record review on 1/7/2025 at 4:00 pm with the DD, Patient 11s medical record titled History of POC/IDG was reviewed. Patient 11s record indicated the following: - POC/IDG, Initial, dated 11/13/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 11s POC/IDGs dated 11/13/2024, 11/27/2024, and 12/11/2924 were missing IDG member signatures and were incomplete. The DD stated it is important to have all members of the IDG present and sign the IDG to show their presence and provide coordination of care among all disciplines. 10. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). A review of Patient 12s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 12s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. The sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. A review of Patient 12s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 12 since the SOC date of 8/6/2024. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the DD, Patient 11s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to assess their emotional or spiritual needs, as well as the family/caregiver and provide support as needed. A review of Patient 12s Electronic Medical Record (EMR) indicated that since Patient 12s recertification date of 11/4/2024, the Spiritual Counselor (SC) did not submit or complete a spiritual assessment, and the Volunteer Coordinator (VC) did not submit or complete a volunteer assessment. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the DD, Patient 12s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a spiritual assessment by SC, and a volunteer assessment by VC, and stated documentation should be submitted within 5 days of Patient 12s recertification date of 11/4/2024. The DD stated it is important for the SC to complete a spiritual assessment of the patient, as indicated in the recertification period, to check if there are any new spiritual and emotional needs of the patient and update the plan of care. The DD also stated it is important to provide the patient with volunteer services because the patient verbalized a need for it, and it is important for the VC to complete a volunteer assessment to identify the patients needs, like companionship, housekeeping, cooking, or errands. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the DD, Patient 12s medical record titled History of POC/IDG was reviewed. Patient 12s record indicated the following: - POC/IDG, Initial, dated 8/7/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 8/21/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 9/4/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/18/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/2/2024 with signatures of the MD and the DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 10/16/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/30/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/13/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 12s POC/IDGs dated 9/4/2024, 9/18/2024, 10/2/2024, 10/16/2024, 10/30/2024, 11/13/2024, 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated the importance of all IDG members to be present, complete and sign the patients IDG is to be able to review the POC together, be on the same page about the patients care and update as needed. 11. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). A review of Patient 13s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 13s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. The sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. A review of Patient 13s Electronic Medical Record (EMR) indicated that since Patient 13s recertification date of 10/31/2024, the MSW did not submit or complete a psychosocial assessment, the SC did not submit or complete a spiritual assessment and the VC did not submit or complete a volunteer assessment. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m. with the DD, Patient 13s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a psychosocial assessment by MSW, spiritual assessment by SC, and a volunteer assessment by VC, and stated documentation should be submitted within 5 days of Patient 13s recertification date of 10/31/2024. The DD stated it is important for all disciplines of the team like MSW, SC and VC to complete their assessment upon Patient 13s recertification to reassess the patients needs, safety of the home, their emotional and spiritual needs as well as the family/caregiver. A review of Patient 13s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 13 since the SOC date of 8/2/2024. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m. with the DD, Patient 13s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to know how the patient is coping, and what the patient and family/caregiver needs are, emotionally and spiritually. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m. with the D), Patient 13s medical record titled History of POC/IDG was reviewed. Patient 13s record indicated the following: - POC/IDG, Initial, dated 8/7/2024 with signatures of the MD, DPCS and MSW, no signature of the SC. - POC/IDG, Updated, dated 8/21/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/4/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/18/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/2/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/16/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/30/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/13/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 13s POC/IDGs dated 8/7/2024, 8/21/2024, 9/4/2024, 9/18/2024, 10/2/2024, 10/16/2024, 10/30/2024, 11/13/2024, 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated the importance of all members of the IDG keep up with the meetings, and complete and sign the POC/IDG is to make sure the patients needs, like safety, care, medications, emotional/spiritual, and eligibility are being updated. 5. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a concurrent interview and record review of Patient 6s medical records on 1/7/2024 at 2:14 PM with DD Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, IDG section, and physician orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 6 on 12/12/2024. DD stated Patient was receiving hospice services without a physicians admission order. DD stated there was no documented evidence that any IDG meetings were conducted since the SOC on 12/12/2024 to review, revise, and document Patient 6s individualized plan of care. DD stated it was important to conduct an IDG meeting to create, update, or resolve the plan of care, including the patient goals, interventions, and outcomes, for Patient 6s problems. DD stated the medical director, RN, MSW, and chaplain must attend the IDG meeting to provide an input in order to provide hospice care to patients (in general) in a holistic (considers the whole body, including mind and body, when treating a person) approach. 6. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease (long-term heart problems due to high blood pressure) with heart failure. During a concurrent interview and record review of Patient 7s medical records on 1/7/2024 at 2:14 PM with DD, Patient 7s ";Comprehensive Nursing Assessment," dated 11/26/2024, IDG section, care plans, and physicians orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 7 on 11/26/2024. DD stated Patient 7 was receiving hospice services without a physicians admission order. DD stated the IDG meetings for Patient 7 were only conducted on 11/27/2024 and 12/11/2024. DD stated the MSW and Chaplain did not sign ";POC/IDG Review," dated 11/27/2024 and 12/11/2024. During an interview on 1/10/2025 at 11:57 AM, the Director of Patient Care Services (DPCS) stated the IDG last conducted the virtual meeting on 12/11/2024. The DPCS stated MSW has not attended any IDG meeting since ";4-5 months ago." The DPCS stated she has not seen the Chaplain virtually or in-person. The DPCS stated the MSW and Chaplain did not attend the IDG meeting if they did not sign the ";POC/IDG Review." The DPCS stated MDS was responsible for assessing the emotional, socioeconomic, and mental aspect of the patient to be able to provide holistic care. The DPCS stated the Chaplain was responsible for providing spiritual comfort to the patient. 7. During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease that causes difficulty breathing). During a concurrent interview and record review of Patient 8s medical records on 1/7/2024 at 2:14 PM with DD, Patient 8s ";Comprehensive Nursing Assessment," dated 11/25/2024, care plans, and physicians orders were reviewed. DD stated there were no hospital records or clinical records prior to hospice admission on file for Patient 8. DD stated RN 1 conducted the initial home visit assessment for Patient 8 on 11/25/2024. DD stated the IDG meetings for Patient 8 were only conducted on 11/27/2024 and 12/11/2024. DD stated the MSW and Chaplain did not sign ";POC/IDG Review," dated 11/27/2024 and 12/11/2024. During an interview on 1/10/2025 at 11:57 AM, the Director of Patient Care Services (DPCS) stated the IDG last conducted the virtual meeting on 12/11/2024. The DPCS stated MSW has not attended any IDG meeting since ";4-5 months ago." The DPCS stated she has not seen the Chaplain virtually or in-person. The DPCS stated the MSW and Chaplain did not attend the IDG meeting if they did not sign the ";POC/IDG Review." The DPCS stated MDS was responsible for assessing Patient 8s emotional, socioeconomic, and mental condition to be able to provide holistic care. The DPCS stated the Chaplain was responsible for providing Patient 8s spiritual comfort to the patient. During an interview on 1/7/2025 at 12:04 p.m. with the Director of Patient Care Services Designee (DD), the DD stated the comprehensive interdisciplinary group meeting were held every two weeks. The DD stated the attendees included the Medical Director 1 (MD1), the Administrator (ADM), the Director of Patient Care Services (DPCS) and sometimes the Spiritual Counselor (SC) and the Medical Social Worker (MSW). The DD stated that the IDG meetings were open to other HA personnel. The DD stated during the IDG meetings each patients issues, medications, and symptoms were discussed. During an interview on 1/7/2025 at 12:04 p.m. with the DD, the DD stated patients Plan of Care (POC – an individualized care planned for each patient) were derived from the IDG meetings. The DD stated the admitting nurse initiates a patients POC, then the IDG follows up to collaborate. The DD stated patients IDG meetings are done to address patients issues and problems and to organize interventions to reach goals. During an interview on 1/8/2025 at 10:50 a.m. with Registered Nurse 1 (RN1), RN1 stated he has not been at the HA for the past two months. The RN1 stated he did not attend the last IDG meeting. The RN1 stated the IDG meetings are held every two weeks. During an interview on 1/8/2025 at 11:41 a.m. with the ADM, the ADM stated the HAs IDG meetings are held every two weeks to discuss patients cases. The ADM stated patients POC are formulated and updated during the IDG meetings. The ADM stated the IDG members include the Medical Director 1 (MD1), DPCS, and the visiting RN. During an interview on 1/8/2025 at 12:10 p.m. with the DPCS, the DPCS stated the HAs last IDG meeting was held on 12/11/2024. The DPCS stated the HA was to have an IDG meeting on 1/8/2025. The DPCS stated the HA has not had an IDG meeting due to the holidays. The DPCS stated IDG meetings are held on Wednesdays. The DPCS stated that if a patient was admitted after 12/11/2024, the patient has not had their IDG meeting because of the holidays. The DPCS stated patients cases are discussed during the IDG meetings. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a record review of Patient 1s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it electronically signed by the DPCS on 12/11/2024. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m. with the DD of Patient 1s electronic medical record (EMR) and physical medical record, the DD stated she did not find documentation or recalled if a comprehensive assessment with all the IDG member was held for Patient 1. The DD stated Patient 1s individualized POC was not completed because the IDG did not meet within five days of Patient 1s start of care. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). During a record review of Patient 2s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, functional limitations, activities permitted, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed. During a record review of Patient 2s medical record form titled ";History of POC/IDG" undated, indicated there were no entries made. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the DD of Patient 2s electronic and physical medical record, the DD stated Patient 2s medical record did not have any documentation that he had an IDG comprehensive assessment. During a concurrent interview and record review on 1/8/2025 at 12:45 p.m. with the DPCS of Patient 2s electronic and physical medical record, the DPCS stated Patient 2s medical record did not indicate his diabetes was being assessed. The DPCS stated Patient 2 has a risk of going into diabetic ketoacidosis (a metabolic condition that occurs when there is a buildup of ketose in the blood which can be life threatening). 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. During a record review of Patient 3s medical record form titled ";History of POC/IDG" undated, indicated there were no entries made. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s electronic and physical medical record, the DD stated Patient 3 did not have an IDG comprehensive meeting assessment. The DD stated Patient 3s POC is not complete, therefore Patient 3 will not get the treatment ordered. During a concurrent interview and record review on 1/8/2025 at 1 p.m. with the DPCS of Patient 3s electronic and physical medical record, the DPCS stated Patient 3 did not have an IDG comprehensive assessment. 4. During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 11/27/2024 and an end of care date of 12/12/2024 with a primary diagnosis of unspecified cirrhosis of the liver. During a record review of Patient 5s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. During a record review of Patient 5s medical record form titled ";History of POC/IDG" undated, indicated there was one entry made on 12/11/2024. During a record review of Patient 5s medical record form titled ";POC/IDG Review" dated 12/11/2024, indicated the Spiritual, psychosocial, and other/physician discussion sections were left blank. The form also indicated Patient 5 did not have any documented problems, interventions, goals, or status. Lastly, the form also indicated the MSW, and the spiritual counselor signatures were missing. During a concurrent interview and record review on 1/7/2025 at 2:17 p.m. with Patient 5s daughter/caregiver, (CG2), CG2 stated Patient 5 was seen by RN1 once and no one else from the HA visited or called. During a concurrent interview and record review on 1/8/2025 at 1:10 p.m. with the DPCS of Patient 5s electronic and physical medical record, the DPCS stated the HA conducted one IDG meeting for Patient 5 dated 12/11/2024. The DPCS stated the MSW and SC did not see Patient 5 therefore were unable to contribute to the IDG meeting discussion. The DPCS stated Patient 5s IDG meeting documentation is missing the MSW and SC signatures because they did not attend the meeting.

Based on interview and record review the Hospice Agency (HA) failed to ensure four of fourteen sampled patients (Patient 6, Patient 7, Patient 8, and Patient 10) care and services were communicated with the hospice team to ensure services were provided as ordered. This failure resulted in HA staff putting patients at risk of harm by not being aware of patients status. --- 10. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). A review of Patient 10s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. During a record review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 11/19/2024 to 2/16/2025, indicated ";Given her comorbidities and terminal diagnosis, she qualifies for hospice care to manage symptoms and provide comfort. Certification for hospice care is recommended based on her terminal condition and current functional status." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 11/19/2024. During a review of Patient 10s medical record form titled ";Comprehensive Nursing Assessment" dated 11/19/2024, indicated RN1s narrative documentation included Patient 10s co-morbidities including arthritis (joint pain), diabetes (high blood sugar), history of pancreatic cancer (cancer to the pancreas), post breast cancer, one kidney removal, Parkinsons tremors (a brain disorder that causes movement problems including tremors), history of heart attack, asthma (chronic lung disease that causes airways to narrow and swell, making it hard to breathe), history of depression (mental health condition that involves constant low mood and loss of interest) and schizophrenia (chronic mental illness that affects a persons thoughts, feelings and behaviors). Lastly, the form indicated it was electronically signed by RN1 on 11/19/2024. During a concurrent interview and record review on 1/7/2025 at 3:45 pm with the DD, Patient 10s medical record titled History of POC/IDG was reviewed. Patient 10s record indicated the following: - POC/IDG, Initial, dated 11/27/2024 with signatures of the Medical Director (MD) and DPCS, no signatures of the Medical Social Worker (MSW) and Spiritual Counselor (SC), and frequency of visit for Skilled Nurse (SN) of one per week and one as needed (PRN) visit. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and the DPCS, no signatures of the MSW and SC, and frequency of visit for Skilled Nurse (SN) of one per week and one as needed (PRN) visit. During a phone interview on 1/8/2025 at 1:45pm with Patient 10s Caregiver (CG1), CG1 stated Patient 10 lives alone in an apartment and is alert and oriented to self and time and is forgetful. CG1 stated she has been caring for Patient 10 since 8/11/2022 and assists her with baths, cooking, cleaning the apartment, and medication administration. CG1 stated since she has been caring for the patient, she has only seen two staff members from the HA come three times to see the patient. CG1 stated the ADM came first to sign up the patient for services, then came again another time to bring Patient 10s medication, and a SN came once in December. During an interview on 1/10/2025 at 11:54pm with the Director of Patient Care Services (DPCS), the DPCS stated during IDG meetings, the SN will give report to the DPCS or MD 1 of patients diagnosis, comorbidities, how they see the patient during visits and reviewed along with their visit documentation. During a concurrent interview and record review on 1/10/2025 at 12:40pm with the Director of Patient Care Services (DPCS), Patient 10s medical record titled History of Visit Notes, was reviewed. The DPCS stated and verified the last documented SN visit for Patient 10 was dated 12/26/2024 by Registered Nurse 1 (RN 1). The DPCS stated there is no documented evidence that Patient 10 was visited the week after 12/26/2024. The DPCS further stated if the SN visit was not documented then the nurse did not do the visit. During an interview on 1/10/2025 at 12:50pm with the DPCS, the DPCS stated submission of SN visit notes are to be within 24 to 48 hours after the visit date. The DPCS stated it is important to submit visit notes within 24 to 48 hours after the visit, because the nurse can forget what they observed on the patient, and it can be difficult to rely on written notes. The DPCS further stated documenting a visit note after 48 hours from the visit can cause the SN to miss a lot of information in their documentation and there would not be continuity of care of the patient between the SNs. During an interview on 1/10/2025 at 2:35pm with RN 1, RN 1 stated if a visit with a patient is scheduled and verified prior to the date, the nurse is to show up to the patients home and if the patient is not there or the nurse is unable to make it then a missed visit note is documented on the patients EMR under the visit notes section. RN 1 stated he did not visit Patient 10 the week after 12/26/2024 because he was sick and unable to make the appointment. The RN 1 further stated he informed the Administrator (ADM) that he was sick and unable to make the visit, and the ADM was going to staff another nurse for the visit. RN 1 also stated he did not make any documentation that he was unable to visit Patient 10, in the EMR. RN 1 stated he is visiting nurse for Patient 10 and has gone to visit her. During a review of the HAs Policy and Procedure (P&P) titled, Missed Visits, with a revised date of April 2019, indicated ";A missed visit will be rescheduled the same week if possible. Missed visits will be documented in the clinical record. The P&P further indicates if a missed visit is not scheduled the clinician will notify the IDG and supervisor of the missed visit with the reason and document it in the patients clinical records to include; patient name, date/ and type of visit, reason for missed visit, description of unmet needs, any other follow up needed, other person notified of the missed visit, and signature of staff member reporting the information. 6. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a concurrent interview and record review of Patient 6s medical records on 1/7/2024 at 2:14 PM with DD Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, IDG section, and physician orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 6 on 12/12/2024. DD stated Patient was receiving hospice services without a physicians admission order. DD stated there was no documented evidence that any IDG meetings were conducted since the SOC on 12/12/2024 to review, revise, and document Patient 6s individualized plan of care. DD stated it was important to conduct an IDG meeting to create, update, or resolve the plan of care, including the patient goals, interventions, and outcomes, for the Patient 6s problems. DD stated the medical director, RN, MSW, and chaplain must attend the IDG meeting to provide an input in order to provide hospice care to patients (in general) in a holistic (considers the whole body, including mind and body, when treating a person) approach. 7. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease (long-term heart problems due to high blood pressure) with heart failure. During a concurrent interview and record review of Patient 7s medical records on 1/7/2024 at 2:14 PM with DD, Patient 7s ";Comprehensive Nursing Assessment," dated 11/26/2024, IDG section, ";POC/IDG Review" dated 11/27/2024 and 12/11/2024, and physicians orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 7 on 11/26/2024. DD stated Patient 7 was receiving hospice services without a physicians admission order. DD stated the IDG meetings for Patient 7 were only conducted on 11/27/2024 and 12/11/2024. DD stated the MSW and Chaplain did not sign ";POC/IDG Review," dated 11/27/2024 and 12/11/2024. During an interview on 1/10/2025 at 11:57 AM, the Director of Patient Care Services (DPCS) stated the IDG last conducted the virtual meeting on 12/11/2024. The DPCS stated MSW has not attended any IDG meeting since ";4-5 months ago." The DPCS stated she has not seen the Chaplain virtually or in-person. The DPCS stated the MSW and Chaplain did not attend the IDG meeting if they did not sign the ";POC/IDG Review." The DPCS stated MSW was responsible for assessing Patient 7s emotional, socioeconomic, and mental condition to be able to provide holistic care. The DPCS stated the Chaplain was responsible for providing Patient 7s spiritual comfort to the patient. DD stated it was important to conduct an IDG meeting to create, update, or resolve the plan of care, including the patient goals, interventions, and outcomes, for the Patient 7s problems. 8. During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease that causes difficulty breathing). During a concurrent interview and record review of Patient 8s medical records on 1/7/2024 at 2:14 PM with DD, Patient 8s ";Comprehensive Nursing Assessment," dated 11/25/2024, care plans, and physicians orders were reviewed. DD stated there were no hospital records or clinical records prior to hospice admission on file for Patient 8. DD stated RN 1 conducted the initial home visit assessment for Patient 8 on 11/25/2024. DD stated the IDG meetings for Patient 8 were only conducted on 11/27/2024 and 12/11/2024. DD stated the MSW and Chaplain did not sign ";POC/IDG Review," dated 11/27/2024 and 12/11/2024. During an interview on 1/10/2025 at 11:57 AM, the Director of Patient Care Services (DPCS) stated the IDG last conducted the virtual meeting on 12/11/2024. The DPCS stated MSW has not attended any IDG meeting since ";4-5 months ago." The DPCS stated she has not seen the Chaplain virtually or in-person. The DPCS stated the MSW and Chaplain did not attend the IDG meeting if they did not sign the ";POC/IDG Review." The DPCS stated MDS was responsible for assessing Patient 8s emotional, socioeconomic, and mental condition to be able to provide holistic care. The DPCS stated the Chaplain was responsible for providing Patient 8s spiritual comfort to the patient. DD stated it was important to conduct an IDG meeting to create, update, or resolve the plan of care, including the patient goals, interventions, and outcomes, for the Patient 8s problems.

Based on interview and record review the Hospice Agency (HA) failed to ensure the Condition of Participation for Licensed Professional Services was met as evidence by: --- 1. The HA failed to provide evidence their licensed providers were authorized and qualified to provide hospice services to thirteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L584). 2. The HA failed to ensure their Medical Social Worker, Physicians, and Spiritual Counselor participated in the planning of patients hospice care by not attending IDT meetings and not contributing to the development of their individualized plan of care for eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13) plan of care (POC- an individualized care planned). (Refer to L585). The cumulative effect of these systemic practices resulted in the HA not ensuring their license personnel were providing services/care as required and had the potential for the patients not receiving appropriate hospice care services that could affect their quality of life.

Based on interview and record review the Hospice Agency (HA) failed to provide evidence their licensed providers were authorized and qualified to provide hospice services to thirteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in patient being taken care of by an unqualified and unauthorized staff. --- 10. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). 11. A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). 12. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). 13. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). During a concurrent interview and record review on 1/10/2025 at 1:10 PM with the Director of Patient Care Services (DPCS), the employee files of HA were reviewed. The DPCS stated the following: 1. There was no documented evidence that RN 1, RN 2, and Licensed Vocational Nurse 1 (LVN 1) had any Skills Competency validation prior to conducting skilled nursing visits to the HA patients. DPCS stated the HA must conduct Skills Competency Validation for licensed nurses upon hire and annually to ensure they are able to perform the job duties related to providing patient care. 2. DPCS stated she did not have any training as DPCS. DPCS stated background checks were not done for RN 1, RN 2, LVN 1, DPCS, and Medical Director. DPCS stated it was important to conduct background checks prior to hiring a prospective employee to ensure the safety of the patients. During a concurrent interview and record review on 1/10/2025 at 1:11pm with the Director of Patient Care Services (DPCS), Registered Nurse 1 (RN 1) employee file was reviewed. RN 1s employee file indicated his skills competency checklist was not complete and there was no evidence of a background check completed. The DPCS stated and verified RN 1s competency checklist was not filled out to indicate if RN 1 was assessed for competency of skills and the file did not include a background check. The DPCS stated the cursive signature next to the Supervisor section was not eligible for her, nor did she recognize it. The DPCS further stated the Administrator (ADM) does the hiring and background check of the staff and she was unaware the RN 1s file did not have a background check done. During a concurrent interview and record review on 1/10/2025 at 1:19pm with the DPCS, Registered Nurse 2s (RN 2) employee file was reviewed. RN 2s employee file indicated her skills competency checklist was not complete and there was no evidence of a background check completed. The DPCS stated and verified RN 2s competency checklist was not filled out to indicate if RN 2 was assessed for competency of skills and the file did not include a background check. The DPCS stated the signature next to the Supervisor section was not eligible for her, nor did she recognize it. The DPCS further stated the ADM does the hiring and was not aware RN 2s file did not have a background check. During a concurrent interview and record review on 1/10/2025 at 1:31pm with the DPCS, the Director of Patient Care Services Designee (DD) employee file was reviewed. The DDs employee file indicated her skills competency checklist was not complete and there was no evidence of a background check completed. The DPCS stated and verified that the DDs competency checklist was not filled out to indicate if she was assessed for competency of skills and the file did not include a background check. The DPCS stated the signature next to the Supervisor section was not eligible for her, nor did she recognize it. The DPCS further stated the ADM does the hiring and was not aware the DDs employee file did not have a background check for her. During an interview on 1/10/2025 at 1:40pm with the DPCS, the DPCS stated it is important to conduct a background check for all agency staff to make sure the HA is not employing anyone with a criminal record for the safety of the patients. 1.During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). 2.During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). 3.During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. 4.During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 11/27/2024 and an end of care date of 12/12/2024 with a primary diagnosis of unspecified cirrhosis of the liver.

Based on interview and record review the Hospice Agency (HA) failed to ensure their Medical Social Worker (MSW) and Spiritual Counselor (SC) participated in the planning of patients hospice care by not attending their interdisciplinary group (IDG – meeting where the Registered Nurse {RN}, MSW, SC, and Physicians come together to discuss patients plan of care to be able to provide the best individualized care and support to patients and families) meetings and not contributing to the development of their individualized plan of care for eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13) plan of care (POC- an individualized care planned). This failure resulted in patients not being properly evaluated which resulted in hospice patients not being provided individualized patient care. --- 10. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). A review of Patient 10s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 10s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. The sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. A review of Patient 10s Electronic Medical Record (EMR) indicated that the Medical Social Worker (MSW) did not submit or complete a psychosocial assessment since Patient 10s SOC of 11/19/2024. During a concurrent interview and record review on 1/7/2025 at 3:45 p.m. with the Director of Patient Care Services Designee (DD), Patient 10s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a psychosocial assessment by the MSW, and documentation should be submitted within 5 days of the SOC date. The DD stated the importance of completing a psychosocial assessment for the patients is to assess safety of their environment at home, see if there are any social issues within the family dynamic, and provide community resources if needed. A review of Patient 10s Electronic Medical Record (EMR) indicated that the Chaplain/Spiritual Counselor (SC) did not submit or complete an initial bereavement assessment for Patient 10 since the SOC date of 11/19/2024. During a concurrent interview and record review on 1/7/2025 at 3:45 p.m. with the Director of Patient Care Services Designee (DD), Patient 10s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete an initial bereavement assessment to assess the support needs of the patient, family or caregiver and assess the emotional and spiritual assistance they would need. During a concurrent interview and record review on 1/7/2025 at 3:45 pm with the DD, Patient 10s medical record titled History of POC/IDG was reviewed. Patient 10s record indicated the following: - POC/IDG, Initial, dated 11/27/2024 with signatures of the Medical Director (MD) and DPCS, no signatures of the Medical Social Worker (MSW) and Spiritual Counselor (SC). - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and the DPCS, no signatures of the MSW and SC. The DD stated and confirmed Patient 10s POC/IDG dated 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated it is important to have a signature of all IDG members on the POC/IDG to validate their attendance in the meeting, and all members are aware of covering all the needs of the patient holistically. 11. A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). A review of Patient 11s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 11s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. The sections allergies, diet, treatment, other, DME (durable medical equipment), and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. A review of Patient 11s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. A review of Patient 11s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 11 since the SOC date of 11/6/2024. During a concurrent interview and record review on 1/7/2025 at 4:00 p.m. with the DD, Patient 11s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to find out the emotional and spiritual needs of the patient and family/caregiver. During a concurrent interview and record review on 1/7/2025 at 4:00 pm with the DD, Patient 11s medical record titled History of POC/IDG was reviewed. Patient 11s record indicated the following: - POC/IDG, Initial, dated 11/13/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 11s POC/IDGs dated 11/13/2024, 11/27/2024, and 12/11/2924 were missing IDG member signatures and were incomplete. The DD stated it is important to have all members of the IDG present and sign the IDG to show their presence and provide coordination of care amongst all disciplines. 12. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). A review of Patient 12s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 12s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. The sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. A review of Patient 12s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 12 since the SOC date of 8/6/2024. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the DD, Patient 11s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to assess their emotional or spiritual needs, as well as the family/caregiver and provide support as needed. A review of Patient 12s Electronic Medical Record (EMR) indicated that since Patient 12s recertification date of 11/4/2024, the Spiritual Counselor (SC) did not submit or complete a spiritual assessment and the Volunteer Coordinator (VC) did not submit or complete a volunteer assessment. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the DD, Patient 12s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a spiritual assessment by SC, and a volunteer assessment by VC, and stated documentation should be submitted within 5 days of Patient 12s recertification date of 11/4/2024. The DD stated it is important for the SC to complete a spiritual assessment of the patient, as indicated in the recertification period, to check if there are any new spiritual and emotional needs of the patient and update the plan of care. The DD also stated it is important to provide the patient with volunteer services because the patient verbalized a need for it, and it is important for the VC to complete a volunteer assessment to identify the patients needs, like companionship, housekeeping, cooking, or errands. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the DD, Patient 12s medical record titled History of POC/IDG was reviewed. Patient 12s record indicated the following: - POC/IDG, Initial, dated 8/7/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 8/21/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 9/4/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/18/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/2/2024 with signatures of the MD and the DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 10/16/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/30/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/13/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 12s POC/IDGs dated 9/4/2024, 9/18/2024, 10/2/2024, 10/16/2024, 10/30/2024, 11/13/2024, 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated the importance of all IDG members to be present, complete and sign the patients IDG is to be able to review the POC together, be on the same page about the patients care and update as needed. 13. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). A review of Patient 13s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 13s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. The sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. A review of Patient 13s Electronic Medical Record (EMR) indicated that since Patient 13s recertification date of 10/31/2024, the MSW did not submit or complete a psychosocial assessment, the SC did not submit or complete a spiritual assessment and the VC did not submit or complete a volunteer assessment. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m. with the DD, Patient 13s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a psychosocial assessment by MSW, spiritual assessment by SC, and a volunteer assessment by VC, and stated documentation should be submitted within 5 days of Patient 13s recertification date of 10/31/2024. The DD stated it is important for all disciplines of the team like MSW, SC and VC to complete their assessment upon Patient 13s recertification to reassess the patients needs, safety of the home, their emotional and spiritual needs as well as the family/caregiver. A review of Patient 13s EMR indicated that the SC did not submit or complete an initial bereavement assessment for Patient 13 since the SOC date of 8/2/2024. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m. with the DD, Patient 13s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of an initial bereavement assessment by the SC, and stated it should be documented and submitted within 5 days of the patients SOC. The DD stated it is important for the SC to assess the patient and complete the initial bereavement assessment to know how the patient is coping, and what the patient and family/caregiver needs are, emotionally and spiritually. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m. with the D), Patient 13s medical record titled History of POC/IDG was reviewed. Patient 13s record indicated the following: - POC/IDG, Initial, dated 8/7/2024 with signatures of the MD, DPCS and MSW, no signature of the SC. - POC/IDG, Updated, dated 8/21/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/4/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/18/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/2/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/16/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/30/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/13/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 13s POC/IDGs dated 8/7/2024, 8/21/2024, 9/4/2024, 9/18/2024, 10/2/2024, 10/16/2024, 10/30/2024, 11/13/2024, 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated the importance of all members of the IDG keep up with the meetings, and complete and sign the POC/IDG is to make sure the patients needs, like safety, care, medications, emotional/spiritual, and eligibility are being updated. 6. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a record review of Patient 6s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, it indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it was not signed. During a record review of Patient 6s medical record form titled ";History of POC/IDG (interdisciplinary group)" undated, indicated there were no entries made. During a concurrent interview and record review of Patient 6s medical records on 1/7/2024 at 2:14 PM with DD Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, IDG section, and physician orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 6 on 12/12/2024. DD stated Patient was receiving hospice services without a physicians admission order. DD stated there was no documented evidence that any IDG meetings were conducted since the SOC on 12/12/2024 to review, revise, and document Patient 6s individualized plan of care. DD stated it was important to conduct an IDG meeting every 15 days to create, update, or resolve the plan of care, including the patient goals, interventions, and outcomes, for the patients (in general) problems. DD stated the medical director, RN, MSW, and chaplain must attend the IDG meeting to provide an input in order to provide hospice care to patients (in general) in a holistic (considers the whole body, including mind and body, when treating a person) approach. 7. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease (long-term heart problems due to high blood pressure) with heart failure. During a record review of Patient 7s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, it indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated the DPCS electronically signed the form on 12/11/2024. During a record review of Patient 7s medical record form titled ";History of POC/IDG (interdisciplinary group)" undated, indicated there were only 2 IDG meetings conducted (11/27/2024 and 12/11/2024) During a concurrent interview and record review of Patient 7s medical records on 1/7/2024 at 2:14 PM with DD, Patient 7s ";Comprehensive Nursing Assessment," dated 11/26/2024, IDG section, ";POC/IDG Review" dated 11/27/2024 and 12/11/2024, and physicians orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 7 on 11/26/2024. DD stated Patient 7 was receiving hospice services without a physicians admission order. DD stated the IDG meetings for Patient 7 were only conducted on 11/27/2024 and 12/11/2024. DD stated there were no MSW and chaplain signatures validating their attendance during Patient 7s IDG meetings on 11/27/2024 and 12/11/2024. 8. During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease that causes difficulty breathing). During a record review of Patient 8s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, it indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated the DPCS electronically signed the form on 12/11/2024. During a record review of Patient 8s medical record form titled ";History of POC/IDG" undated, it indicated there were only 2 IDG meetings (11/27/2024 and 12/11/2024) conducted. During a concurrent interview and record review of Patient 8s medical records on 1/7/2024 at 2:14 PM with DD, Patient 7s ";Comprehensive Nursing Assessment," IDG section, ";POC/IDG Review" dated 11/27/2024 and 12/11/2024, and physicians orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 8 on 11/25/2024. DD stated Patient 8 was receiving hospice services without a physicians admission order. DD stated the IDG meetings for Patient 8 were only conducted on 11/27/2024 and 12/11/2024. DD stated there were no MSW and chaplain signatures validating their attendance during Patient 8s IDG meetings on 11/27/2024 and 12/11/2024. During an interview on 1/7/2025 at 12:04 p.m. with the Director of Patient Care Services Designee (DD), the DD stated the comprehensive interdisciplinary group meeting were held every two weeks. The DD stated the attendees included the Medical Director 1 (MD1), the Administrator (ADM), the Director of Patient Care Services (DPCS) and sometimes the Spiritual Counselor (SC) and the Medical Social Worker (MSW). The DD stated during the IDG meetings each patients issues, medications, and symptoms were discussed. During an interview on 1/7/2025 at 12:04 p.m. with the DD, the DD stated patients Plan of Care (POC – an individualized care planned for each patient) were derived from the IDG meetings. The DD stated the admitting nurse initiates a patients POC, then the IDG follows up to collaborate. The DD stated patients IDG meetings are done to address patients issues and problems and to organize interventions to reach goals. During an interview on 1/8/2025 at 10:50 a.m. with Registered Nurse 1 (RN1), RN1 stated he has not been at the HA for the past two months. The RN1 stated he did not attend the last IDG meeting. The RN1 stated the IDG meetings are held every two weeks. During an interview on 1/8/2025 at 11:41 a.m. with the ADM, the ADM stated the HAs IDG meetings are held every two weeks to discuss patients cases. The ADM stated patients POC are formulated and updated during the IDG meetings. The ADM stated the IDG members include the Medical Director 1 (MD1), DPCS, and the visiting RN. During an interview on 1/8/2025 at 12:10 p.m. with the DPCS, the DPCS stated the HAs last IDG meeting was held on 12/11/2024. The DPCS stated the HA was to have an IDG meeting on 1/8/2025. The DPCS stated the HA has not had an IDG meeting due to the holidays. The DPCS stated IDG meetings are held on Wednesdays. The DPCS stated that if a patient was admitted after 12/11/2024, the patient has not had their IDG meeting because of the holidays. The DPCS stated patients cases are discussed during the IDG meetings. 1.During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a record review of Patient 1s medical record form titled ";POC (plan of care) Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME (durable medical equipment), supplies, and lab were left blank. The form also indicated it electronically signed by the DPCS on 12/11/2024. During a record review of Patient 1s medical record form titled ";History of POC/IDG (interdisciplinary group)" undated, indicated there were no entries made. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m. with the DD of Patient 1s electronic medical record (EMR) and physical medical record, the DD stated she did not find documentation or recalled if a comprehensive assessment with all the IDG member was held for Patient 1. The DD stated Patient 1s individualized POC was not completed because the IDG did not meet within five days of Patient 1s start of care. 2.During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). During a record review of Patient 2s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, functional limitations, activities permitted, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed. During a record review of Patient 2s medical record form titled ";History of POC/IDG" undated, indicated there were no entries made. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the DD of Patient 2s electronic and physical medical record, the DD stated Patient 2s medical record did not have any documentation that he had an IDG comprehensive assessment. During a concurrent interview and record review on 1/8/2025 at 12:45 p.m. with the DPCS of Patient 2s electronic and physical medical record, the DPCS stated Patient 2s medical record did not indicate his diabetes was being assessed. The DPCS stated Patient 2 has a risk of going into diabetic ketoacidosis (a metabolic condition that occurs when there is a buildup of ketose in the blood which can be life threatening). 3.During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. During a record review of Patient 3s medical record form titled ";History of POC/IDG" undated, indicated there were no entries made. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s electronic and physical medical record, the DD stated Patient 3 did not have an IDG comprehensive meeting assessment. The DD stated Patient 3s POC is not complete, therefore Patient 3 will not get the treatment ordered. During a concurrent interview and record review on 1/8/2025 at 1 p.m. with the DPCS of Patient 3s electronic and physical medical record, the DPCS stated Patient 3 did not have an IDG comprehensive assessment. 4.During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 11/27/2024 and an end of care date of 12/12/2024 with a primary diagnosis of unspecified cirrhosis of the liver. During a record review of Patient 5s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. During a record review of Patient 5s medical record form titled ";History of POC/IDG" undated, indicated there was one entry made on 12/11/2024. During a record review of Patient 5s medical record form titled ";POC/IDG Review" dated 12/11/2024, indicated the Spiritual, psychosocial, and other/physician discussion sections were left blank. The form also indicated Patient 5 did not have any documented problems, interventions, goals, or status. Lastly, the form also indicated the MSW, and the spiritual counselor signatures were missing. During a concurrent interview and record review on 1/7/2025 at 2:17 p.m. with Patient 5s daughter/caregiver, (CG2), CG2 stated Patient 5 was seen by RN1 once and no one else from the HA visited or called. During a concurrent interview and record review on 1/8/2025 at 1:10 p.m. with the DPCS of Patient 5s electronic and physical medical record, the DPCS stated the HA conducted one IDG meeting for Patient 5 dated 12/11/2024. The DPCS stated the MSW and SC did not see Patient 5 therefore were unable to contribute to the IDG meeting discussion. The DPCS stated Patient 5s IDG meeting documentation is missing the MSW and SC signatures because they did not attend the meeting.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Core Services was met as evidenced by: --- 1. The HA failed to ensure ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13) had their terminal illness managed and overseen by a physician. (Refer to L590). 2. The HA failed to ensure four of fourteen sampled patients (Patient 1, Patient 2, Patient 3, and Patient 5) were provided bereavement counseling. (Refer to L596). The cumulative effect of these systemic practices resulted in the HA not providing the core services/care as required and had the potential for the patients not receiving appropriate healthcare services that could affect their quality of life.

Based on interview and record review the Hospice Agency (HA) failed to ensure ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13) had their terminal illness managed and overseen by a physician. This failure resulted in patients receiving hospice services without being certified for hospice care and without a physician oversight which had the potential to cause harm and distress to the patients by not having their needs met while dealing with their end of life. --- During an interview on 1/10/2025 at 3:03pm, with the Administrator (ADM), the ADM stated he knows that all fourteen active patients form the HA do not have admission or treatment orders for hospice services. The ADM stated lately he has not been able to get ahold of the Medical Director 2 (MD2), or the physicians working under him for the orders. 10. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). A review of Patient 10s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefit- Statement for first 90-day period" dated 11/19/2024, indicated Registered Nurse 1 (RN 1) obtained verbal authorization from the Medical Director 2 (MD 2) to admit Patient 10 for hospice services. The form also indicated it was not signed by the MD2 and it did not state if MD2 wanted to follow Patient 10s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 11/19/2024 to 2/16/2025, indicated ";Given her comorbidities and terminal diagnosis, she qualifies for hospice care to manage symptoms and provide comfort. Certification for hospice care is recommended based on her terminal condition and current functional status." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 11/19/2024. A review of Patient 10s medical record form titled ";Audit Log" dated from 11/1/2024 to 1/7/2025, indicated MD1 signed Patient 10s CTI dated 11/19/2024 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 3:45 p.m. with the Director of Patient Care Services Designee (DD), Patient 10s Electronic Medical Record (EMR) and physical medical record were reviewed. The DD stated Patient 10 was referred by MD2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 10 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 10s medical records did not contain her history and/or physical, or hospital records therefore, the Hospice Agency (HA) does not have any evidence to support Patient 10s documented LCD. During a concurrent interview and record review on 1/10/2025 at 1:06pm with the DPCS, Patient 10s medical record titled, Audit Log, dated from 11/1/2024 to 1/7/2025 was reviewed. The DPCS stated and verified that the MD1 documented and signed Patient 10s CTI twenty-four days past the indicated date documented on the CTI. The DPCS stated it is important for the MD1 to document his findings on the same day to verify patients hospice eligibility and recall all the findings. 11. A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). A review of Patient 11s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 11s medical record form titled ";Physicians Certification for Hospice Benefit- Statement for first 90-day period" dated 11/6/2024, indicated the Skilled Nurse (SN) obtained verbal authorization from the Medical Director 2 (MD 2) to admit Patient 11 for hospice services. The form also indicated it was not signed by the MD2 and it did not state if MD2 wanted to follow Patient 11s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 11s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 11/6/2024 to 2/3/2025, indicated ";Due to the progression of atherosclerotic heart disease, worsening comorbidities, and overall decline in health, the patient meets LCD eligibility for hospice care." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 11/6/2024. A review of Patient 11s medical record form titled ";Audit Log" dated from 11/1/2024 to 1/7/2025, indicated MD1 signed Patient 11s CTI dated 11/6/2024 on 11/17/2024. During a concurrent interview and record review on 1/7/2025 at 4:00 p.m. with the Director of Patient Care Services Designee (DD), Patient 11s Electronic Medical Record (EMR) and physical medical record were reviewed. The DD stated Patient 11 was referred by MD 2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 11 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 11s medical records did not contain her history and/or physical, or hospital records therefore, the Hospice Agency (HA) does not have any evidence to support Patient 11s documented LCD. During a concurrent interview and record review on 1/10/2025 at 1:06pm with the DPCS, Patient 11s medical record titled, Audit Log, dated from 11/1/2024 to 1/7/2025 was reviewed. The DPCS stated and verified that the MD1 documented and signed Patient 11s CTI eleven days past the indicated date documented on the CTI. The DPCS stated it is important for the MD1 to document his findings on the same day to verify patients hospice eligibility and recall all the findings. During a concurrent interview and record review on 1/10/2025 at 3:32pm with the Administrator (ADM), Patient 11s EMR and physical medical record were reviewed. The ADM stated and verified Patient 11 did not have a referral from a physician, clinic, or hospital to the Hospice Agency (HA). 12. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). A review of Patient 12s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefit- Statement for first 90-day period" dated 8/6/2024, indicated Registered Nurse 1 (RN 1) obtained verbal authorization from the Medical Director 2 (MD 2) to admit Patient 12 for hospice services. The form also indicated it was not signed by the MD2 and it did not state if MD2 wanted to follow Patient 12s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #2: Statement for second 90-day period" dated 11/4/2024 to 2/1/2025, indicated ";Due to the patients poor prognosis, worsening comorbidities, and ongoing decline, the patient and family have opted to continue hospice care for comfort measures. The patient meets LCD eligibility criteria for the second benefit period." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 11/4/2024. A review of Patient 12s medical record form titled ";Audit Log" dated from 8/1/2024 to 1/7/2025, indicated MD1 signed Patient 12s CTI dated 11/4/2024 on 11/17/2024. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the Director of Patient Care Services Designee (DD), Patient 12s Electronic Medical Record (EMR) and physical medical record were reviewed. The DD stated Patient 12 was referred by MD2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 12 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 12s medical records did not contain her history and/or physical, or hospital records therefore, the Hospice Agency (HA) does not have any evidence to support Patient 12s documented LCD. During a concurrent interview and record review on 1/10/2025 at 1:06pm with the DPCS, Patient 12s medical record titled, Audit Log, dated from 8/1/2024 to 1/7/2025 was reviewed. The DPCS stated and verified that the MD1 documented and signed Patient 12s CTI thirteen days past the indicated date documented on the CTI. The DPCS stated it is important for the MD1 to document his findings on the same day to verify patients hospice eligibility and recall all the findings. During a concurrent interview and record review on 1/10/2025 at 3:32pm with the Administrator (ADM), Patient 12s EMR and physical medical record were reviewed. The ADM stated and verified Patient 12 did not have a referral from a physician, clinic, or hospital to the Hospice Agency (HA). 13. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). A review of Patient 13s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 13s medical record form titled ";Physicians Certification for Hospice Benefit- Statement for first 90-day period" dated 8/2/2024, indicated Registered Nurse 1 (RN 1) obtained verbal authorization from the Medical Director 2 (MD 2) to admit Patient 13 for hospice services. The form also indicated it was not signed by the MD2 and it did not state if MD2 wanted to follow Patient 13s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 13s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #2: Statement for Second 90-day period" dated 10/31/2024 to 1/28/2025, indicated ";Hospice Medical Director has certified for the 2nd benefit period that the patient has a terminal illness with a life expectancy of six months or less if the disease process will take its normal course." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 10/31/2024. A review of Patient 13s medical record form titled ";Audit Log" dated from 8/1/2024 to 1/7/2025, indicated MD1 signed Patient 13s CTI dated 10/31/2024 on 11/17/2024. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m. with the Director of Patient Care Services Designee (DD), Patient 13s Electronic Medical Record (EMR) and physical medical record were reviewed. The DD stated Patient 13 was referred by MD2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 13 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 13s medical records did not contain her history and/or physical, or hospital records therefore, the Hospice Agency (HA) does not have any evidence to support Patient 13s documented LCD. During a concurrent interview and record review on 1/10/2025 at 1:06pm with the DPCS, Patient 13s medical record titled, Audit Log, dated from 8/1/2024 to 1/7/2025 was reviewed. The DPCS stated and verified that the MD1 documented and signed Patient 13s CTI seventeen days past the indicated date documented on the CTI. The DPCS stated it is important for the MD1 to document his findings on the same day to verify patients hospice eligibility and recall all the findings. During a concurrent interview and record review on 1/10/2025 at 3:32pm with the Administrator (ADM), Patient 13s EMR and physical medical record were reviewed. The ADM stated and verified Patient 13 did not have a referral from a physician, clinic, or hospital to the Hospice Agency (HA). 6. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a record review of Patient 6s medical record form titled ";Physicians Order" dated 1/4/2025, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 6s medical record form titled ";LCD Hospice Eligibility Determination," dated 12/12/2024, it indicated Patient 6 did not qualify per LCD guidelines. The ";LCD Hospice Eligibility Determination" indicated Patient 6 did not meet the following qualifying factors: 1. Unable to dress without assistance. 2. Unable to bathe without assistance. 3. Urinary and fecal incontinence (inability to voluntary control urine or bowel movement) is intermittent or constant/dependent on catheter (thin, flexible tube that can be inserted into the body) or ostomy (surgical opening in the body to help remove waste) care. 4. Unable to consistently have meaningful verbal communication; utters stereotypical phrases only, or ability to speak six or fewer intelligible words. The ";LCD Hospice Eligibility Determination" indicated Patient 6 had inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous 6 months or serum albumin (laboratory test that measures the protein in the blood that helps maintain fluid balance) was less than 2.5 grams per deciliter. During a record review of Patient 6s medical record form, titled ";Comprehensive Nursing Assessment," dated 12/12/2024, the ";Comprehensive Nursing Assessment" indicated the following: 1. Patient 6 was alert; oriented to self, place, and time. 2. Patient 6 was able to verbalize needs and concerns. 3. Patient 6 was continent of urine. 4. Patient 6 required ";occasional assistance" but was able to care for most of her personal needs and was able to ambulate with a cane or a walker. During a concurrent interview and record review of Patient 6s medical records on 1/7/2024 at 2:14 PM with DPCS designee (DD), Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, ";CTI," dated 12/13/2024, ";LCD Hospice Eligibility Determination," dated 12/12/2024, and physicians orders were reviewed. DD stated there was no documented evidence that Patient 6 had inability to maintain sufficient fluid and caloric intake with 10% weight loss during the previous 6 months or serum albumin level less than 2.5 gm/dl. DD stated the lack of objective data could lead to Patient 6s inaccurate assessment and would not support Patient 6s eligibility for hospice services. DD stated RN 1 conducted the initial home visit assessment for Patient 6 on 12/12/2024. DD stated Patient was receiving hospice services without a physicians admission order. During an interview on 1/10/2025 at 11:57 AM, the DPCS stated the Administrator, who was not a licensed nurse or physician, was responsible for determining a patients (in general) eligibility for hospice services. The DPCS stated she has not communicated with the referring physician or healthcare facility to request for the patients (in general) medical records to determine and support hospice eligibility. The DPCS stated she ";assumed" the Administrator had requested the medical records prior to the patients (in general) admission to HA. The DPCS stated she reviewed the hospice eligibility based on the admitting Registered Nurses ";Comprehensive Nursing Assessment." During an interview on 1/10/2025 at 1:41 PM, Registered Nurse 1 (RN 1) stated the Administrator would inform RN 1 if a patient (in general) would be admitted to HA. RN 1 stated HA would provide the patients name, address, and complaints. RN 1 stated he conducted his ";Comprehensive Nursing Assessment" based on the patients (in general) and/or caregivers responses. RN 1 stated he did not review the patients (in general) medical records from the hospital or any documentation from any healthcare facility. During an interview on 1/10/2025 at 3:01 PM, the Administrator (ADM) stated he reviewed all patient referrals. ADM stated he obtained his patient referrals from the ";clinics, hospitals, and personal referrals." ADM stated Patient 6 was referred by Referral Person (RP) who ";worked at a clinic." ADM was unable to present any documented evidence of a referral from a clinic or a hospital that included Patient 6s medical records that supported Patient 6s eligibility to receive hospice services. During an interview on 1/10/2025 at 3:37 PM, RP stated she worked at a ";non-profit organization that handles referrals" to different agencies for individuals from drug rehabilitation centers, shelters, crisis centers, and/or for those at risk for suicide. RP stated she did not work directly for HA 1. RP stated she would ";begin the process" by sending out referrals but would not make the determination for eligibility for services. 7. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease with heart failure. During a record review of Patient 7s medical record form, titled ";Physicians Order" dated 12/19/2024, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 7s medical record form titled ";LCD Hospice Eligibility Determination," dated 11/26/2024, it indicated Patient 7s qualifying factors included: 1. Patient optimally treated for heart disease with diuretics (medications that increase urine production to get rid of excess fluid) and vasodilators (medications that open blood vessels to increase blood flow to organs). 2. Patient meet the criteria for New York Heart Association (NYHA) Class IV level (most severe class of heart failure resulting in inability to carry on physical activity without discomfort due to symptoms of heart failure at rest or with minimal exertion). During a record review of Patient 7s medical record form, titled ";Comprehensive Nursing Assessment," dated 11/26/2024, the ";Comprehensive Nursing Assessment" indicated the following: 1. Patient 7 was alert; oriented to self, place, and time; and was able to verbalize needs and concerns. 2. Patient 7 had normal systolic blood pressure (SBP, measure of the force of blood pushing against artery walls during heart contraction with normal levels less than 120 mmHg) at 91-159. 3. Patient 7 had regular apical pulse (heart rate obtained by listening directly to the heartbeat using a stethoscope), pedal pulse (heart rate obtained by palpating the foot or using an ultrasound device) and radial pulse (heart rate obtained by palpating the radial artery of the wrist). 4. Patient 7 has no cardiac-related (heart-related) pain. 5. Patient 7 had a 2+ edema (slight swelling in the tissues due to fluid buildup with 4+ being most severe) to both lower extremities. 6. Patient 7 had mild dyspnea (SOB, shortness of breath) with mild exertion. 7. Patient 7 had normal respirations (breathing) with no cough. 8. Patient 7 ";required occasional assistance" but was able to care for most of his personal needs. During a concurrent interview and record review of Patient 7s medical records on 1/7/2024 at 2:14 PM with DD, Patient 7s ";Comprehensive Nursing Assessment," dated 11/26/2024, ";CTI," dated 11/26/2024, ";LCD Hospice Eligibility Determination," dated 11/26/2024, and physicians orders were reviewed. DD stated RN 1 documented that Patient 7 met the criteria for NYHA Class IV level but lacked documented evidence to support Patient 7s eligibility for hospice services. DD stated RN 1 conducted the initial home visit assessment for Patient 7 on 11/26/2024. DD stated Patient 7 was receiving hospice services without a physicians admission order. During an interview on 1/10/2025 at 1:41 PM, RN 1 stated he identified Patient 7 has NYHA Class IV level because Patient 7 had ";SOB after walking for a long time from the kitchen to the living room," had ";congested lungs," and had a ";history of chest pain and heart attack." RN 1 was unable to state the criteria in determining when a patient (in general) qualified for NYHA Class III or a Class IV level. RN 1 stated he did not review any medical records from Patient 7, HA 1, or from the hospital/clinic. During an interview on 1/10/2025 at 3:01 PM, ADM stated Patient 7 was referred by RP who ";worked at a clinic." ADM was unable to present any documented evidence of a referral from a clinic or a hospital that included Patient 7s medical records that supported Patient 7s eligibility to receive hospice services. 8. During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of COPD. During a record review of Patient 8s medical record form, titled ";Physicians Order" dated 12/11/2024, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 8s medical record form, titled ";LCD Hospice Eligibility Determination," dated 11/25/2024, it indicated Patient 8s qualifying factors included: 1. Poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. 2. Increasing visits to the emergency room, and 3. Hypoxemia (low level of oxygen in the blood) at rest on room air, as evidenced by pO2 (pO2, measure of the tension or pressure of oxygen dissolved in the blood obtained through a blood test or pulse oximetry) less than or equal to 55 millimeters of mercury (mmHG, unit of measurement of pressure). During a record review of Patient 8s medical record form, titled ";Comprehensive Nursing Assessment," dated 11/25/2024, the ";Comprehensive Nursing Assessment" indicated the following: 1. Patient 8 was alert; oriented to self, place, and time; and was able to verbalize needs and concerns. 2. Patient 8 had episodes of severe SOB by walking to the front door of his house. 3. Patient 8 had moderate SOB with mild exertion, labored respirations with crackles (abnormal lung sounds) but no coughing. 4. Patient 8 was on oxygen therapy at 2 liters per minute via nasal cannula (thin, flexible tube that delivers supplement oxygen through the nose). 5. RN 1 did not document whether oxygen therapy was administered continuously or as needed. 6. RN 1 did not document Patient 8s oxygen saturation (amount of oxygen in the blood with normal values ranging from 95% to 100% that could be obtained via pulse oximetry (non-invasive method that measures the amount of oxygen in the blood). During a concurrent interview and record review of Patient 8s medical records on 1/7/2024 at 2:14 PM with DD, Patient 8s ";Comprehensive Nursing Assessment," dated 11/25/2024, ";CTI," dated 11/25/2024, ";LCD Hospice Eligibility Determination," dated 11/25/2024, and physicians orders were reviewed. DD stated DD stated RN 1 documented Patient 8 had ";hypoxemia at rest on room air, but there was no documented evidence of pO2 in Patient 8s medical records. DD stated RN 1 conducted the initial home visit assessment for Patient 8 on 11/25/2024. DD stated Patient 8 was receiving hospice services without a physicians admission order. During an interview on 1/10/2025 at 1:41 PM, RN 1 stated he did not review any medical records from Patient 8, HA 1, or from the hospital/clinic. During an interview on 1/10/2025 at 3:01 PM, ADM stated Patient 8 was referred by RP who ";worked at a clinic." ADM was unable to present any documented evidence of a referral from a clinic or a hospital that included Patient 8s medical records that supported Patient 8s eligibility to receive hospice services. During an interview on 1/8/2025 at 11:21 a.m. with the Medical Doctor 2 (MD2), MD 2 stated he does not work for or has heard of the HA. MD2 stated he is not the HAs referring physician. MD2 stated he does not work in Los Angeles County. During an interview on 1/10/2025 at 10 a.m. with the Medical Director 1 (MD1) MD1 stated he had been the HAs medical director since 2023. MD1 stated Medical Doctor 2 (MD2) was the referring physician for the patients and that he has never met him. MD1 stated his duties were to coordinate patients medical care. MD1 stated patients Local Coverage of Determination (LCD - a tool used to determine if a patient meets hospice care based on specific criteria) were completed by the Director of Patient Care Services (DPCS) and they were based on the initial nursing visit assessments. MD1 stated he completes the patients Certification of Terminal Illness (CTI - a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician) with the information provided by the referring physician, admitting Registered Nurse (RN) and the DPCS. MD1 stated there has been times when he signs patients CTI late. MD1 stated before they provide any patient care or visits the HA should obtain a referral order and the patients histories and physicals (H&P). During an interview on 1/10/2025 at 10:20 a.m. with the MD1, MD1 stated he has not seen any patients H&P. MD1 stated he has not spoken or seen any HA patients since being hired in 2023. MD1 stated he receives the patients information from the DPCS. MD1 stated he documents in the physician narrative section of patients CTI based on what the DPCS reports to him. MD1 stated he provides all the admitting, medication, and treatment orders to the DPCS during their interdisciplinary meetings. MD1 was made aware the current HA patients did not have any admitting or treatment orders. MD1 stated, ";I should be more, I should not have been more, I should be more demanding." During an interview on 1/10/2025 at 12:30 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated she based the patients care plans on the initial nursing assessment. During an interview on 1/10/2025 at 3 p.m. with the Administrator (ADM), the ADM stated he receives all the patients referrals from clinics, hospitals, and some personal. The ADM stated the current HA patients have been referred by MD2 with the assistance of the Referral Person (RP). The ADM stated he has been behind and has not had a change to contact MD2 for patients admitting orders, H&P, diagnostic, or medication list. The ADM stated he contacts the Nurse Practitioner 1 (NP1) who works under MD2. The ADM was requested to provide NP1s telephone number. The ADM stated he did not know NP1s telephone number. During an interview on 1/10/2025 at 3:37 p.m. with the Referral Person (RP), RP stated she is a licensed medical social worker that works for a non-profit organization that assist in referring inpatients, outpatient, persons in drug rehab and shelters from one program to another. The RP stated she contacts the programs to let them know when a person is interested but that it is up to the program to admit or not. 1.During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). Lastly, the form indicated Medical Director 1 (MD1) was listed under ";Medical Director" and Medical Doctor 2 (MD2) was listed under ";Referring/Attending/Patient Choice". During a record review of Patient 1s medical record form titled ";Physician Order" dated 1/4/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 1s medical record form titled ";LCD Hospice Eligibility Determination" dated 12/13/2024, indicated Patient 1s qualifying factors included 1. Poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. 2. Increased visit to the emergency room. 3. Oxygen saturation less than or equal to 88% determined either by arterial blood gases or oxygen saturation monitors (these values may be obtained from recent hospital records) and 4. Unintentional progressive weight loss > or = 10% of body weight over last six months. During a record review of Patient 1s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 1s oxygen saturation was at 96%, but it does not indicate if his oxygen reading was with the use of oxygen or not. The form indicated Registered Nurse 1 (RN1)s narrative documentation included Patient 1s co-morbidities including diabetes (high blood sugar), arthritis (joint pain), scoliosis (abnormal spine curvature), and hypertension (high blood pressure). Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m. with the Director of Patient Care Services Designee (DD) of Patient 1s Electronic Medical Record (EMR) and physical medical record, the DD stated Patient 1 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 1 was receiving oxygen from the HA without a physicians order. The DD stated Patient 1s diabetes was not being assessed by the HA. The DD stated she did not know if the family was managing Patient 1s diabetes. The DD stated Patient 1 can experience confusion, coma, or death if his blood sugar goes too high or too low. The DD stated diabetes complications can be prevented if managed correctly. The DD stated Patient 1s medical records did not contain his history and/or physical, therefore, the HA does not have any evidence to support Patient 1s documented LCD. During an interview on 1/8/2025 at 7:57 a.m. with Patient 1, Patient 1 stated he was not a hospice patient and that he wants ";to live a little bit longer". Patient 1 stated he has not heard of MD1, MD2, or RN1. During an interview on 1/8/2025 at 10:50 a.m. with RN1, RN1 stated he conducted Patient 1s initial assessment on 12/13/2025. RN1 stated requesting Patient 1s medical records from his primary physician, Patient 1 and from the HAs ADM and DPCS. RN1 stated he reviews patients medications and if they have medications for diabetes, he asks about it. RN1 stated Patient 1 ";probably" told him what his blood sugar reading was, but RN1 did not document that. RN1 stated he spoke with MD2 about Patient 1 at which time he received verbal orders from MD2. RN1 was unable to provide MD2s phone number. During a concurrent interview and record review on 1/8/2025 at 12:10 p.m. with the DPCS of Patient 1s EMR and physical medical record, the DPCS stated RN1 provided Patient 1s initial home visit assessment on 12/13/2024 but signed it on 12/26/2024. The DPCS stated Patient 1 is receiving hospice services without a physician admission order. During a concurrent interview and record review on 1/8/2025 at 12:35 p.m. with the DPCS of Patient 1s EMR and physical medical record, the DPCS stated Patient 1 does not have any treatment orders. The DPCS stated it was important to have completed patient documents for liability reasons. The DPCS stated the HA did not have Patient 1s history and physical, or any documented evidence that supports the admitting nurses assessment. The DPCS stated there were no physical documents to attest to Patient 1s assessment. 2.During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). Lastly, the form indicated MD1 was listed under ";Medical Director" and MD2 was listed under ";Referring/Attending/Patient Choice". During a record review of Patient 2s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 2s medical record form titled ";LCD Hospice Eligibility Determination" dated 12/13/2024, indicated Patient 2s qualifying factors included 1. Is patient optimally treated for heart disease with diuretics and vasodilators. 2. Does this CHF or angina patient meet the criteria for New York Heart Association (NYHA – a system for categorizing the severity of heart failure based on a patients physical activity limitations) Class IV (unable to carry out any physical activity without discomfort) level. During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated RN1s narrative documentation included Patient 1s co-morbidities including diabetes, arthritis, depression, and open-heart surgery. RN1s documented narrative also included ";Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort." Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the DD of Patient 2s EMR and physical medical record, the DD stated Patient 2 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 2s medical records did not contain his history and/or physical, therefore, the HA does not have any evidence to support Patient 2s documented LCD. During an interview on 1/8/2025 at 8:12 a.m. with Patient 2, Patient 2 stated he was not dying, and that no one ever told him he was dying. Patient 2 stated he was referred by a friend of a friend, who also told him that he would get nutrition supplement and a blood sugar reading machine. Patient 2 stated he sees had a cardiologist and a primary doctor (MD3). Patient 2 stated I am not dying, only God knows when Ill die. During an interview on 1/8/2025 at 11 a.m. with Medical Doctor 3 (MD3), MD3 stated she was Patient 2s primary physician. MD3 stated she last saw Patient 2 on 11/14/2024. MD3 stated she did not refer Patient 2 for hospice services. MD3 stated Patient 2 has chronic illnesses but is a ";pretty healthy man". During a concurrent interview and record review on 1/8/2025 at 12:45 p.m. with the DPCS of Patient 2s electronic and physical medical record, the DPCS stated RN1 documented Patient 2s LCD form incorrectly. The DPCS stated Patient 2s medical record did not indicate his diabetes was being assessed. The DPCS stated Patient 2 has a risk of going into diabetic ketoacidosis (a metabolic condition that occurs when there is a buildup of ketose in the blood which can be life threatening). 3.During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. Lastly, the form indicated MD1 was listed under ";Medical Director" and MD2 was listed under ";Referring /Attending/Patient Choice". During a record review of Patient 3s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 3s medical record form titled ";LCD Hospice Eligibility Determination" dated 12/13/2024, indicated Patient 3s qualifying factors included 1. Poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. 2. Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, less than 30% of predicted. 3. Increased visit to the emergency room and 4. Oxygen saturation less than or equal to 88% determined either by arterial blood gases or oxygen saturation monitors (these values may be obtained from recent hospital records). During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated RN1s narrative documentation included Patient 3s co-morbidities including diabetes, arthritis, gastritis (stomach pain) and osteoporosis (weak and brittle bones). RN1s documented narrative also included ";The patients current condition, medication, and treatments have been recorded and reviewed with MD via telephone and ordered to continue the medications and treatments upon admission." Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s electronic and physical medical record, the DD stated Patient 3 was not receiving oxygen from the HA. The DD stated Patient 3s diabetes was not being assessed. The DD stated Patient 3s medical records did not contain her history and/or physical, therefore, the HA does not have any evidence to support Patient 3s documented LCD. During a concurrent interview and record review on 1/8/2025 at 1 p.m. with the DPCS of Patient 3s electronic and physical medical record, the DPCS stated RN1 provided Patient 3s initial home visit assessment on 12/13/2024. The DPCS stated Patient 3 is receiving hospice services without a physician admission or treatment orders. The DPCS stated Patient 3s medical record did not contain documented evidence to support RN1s documentation.

Based on interview and record review the Hospice Agency (HA) failed to ensure four of fourteen sampled patients (Patient 1, Patient 2, Patient 3, and Patient 5) were provided bereavement counseling. This failure had the potential to result in patients and their families/care givers are not aware of the resources needed to manage the end-of-life process. It also had the potential to cause unnecessary pain and suffering to patients families/care givers. --- 1.During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a record review of Patient 1s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 1 was referred to the Medical Social Worker (MSW) and the Spiritual Counselor (SC). Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 1s medical record form titled ";History of Bereavement Assessment" undated, did not indicate there were entries made. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m. with the Director of Patient Care Services Designee (DD) of Patient 1s Electronic Medical Record (EMR) and physical medical record, the DD stated she did not know if Patient 1 had an initial bereavement assessment which should have been completed by the Spiritual Counselor (SC) within a week of start of care. The DD stated the bereavement assessment was important to determine if the family or caregiver can benefit from grief support. The DD stated if the bereaved persons do not receive grief support, they might go through depression. During a concurrent interview and record review on 1/8/2025 at 12:10 p.m. with the Director of Patient Care Services (DPCS) of Patient 1s electronic and physical medical record, the DPCS stated Patient 1s initial bereavement assessment was not done. The DPCS stated a bereavement assessment was important, to know if the family or the patient required spiritual services while receiving hospice care. 2.During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 2 was referred to the MSW, SC, and Volunteer. Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the DD of Patient 2s electronic and physical medical record, the DD stated Patient 2 did not have a bereavement assessment. The DD stated Patient 2s bereavement assessment should have been completed by the SC within five days of start of care. The DD stated Patient 2s bereavement assessment was needed to be able to provide Patient 2s family with emotional and spiritual support. 3.During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated under section ";Referrals", Patient 3 was referred to the MSW, SC, and Volunteer. Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 3s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a concurrent interview and record review on 1/8/2025 at 1 p.m. with the DPCS of Patient 3s electronic and physical medical record, the DPCS stated Patient 3 did not have a bereavement assessment. 4.During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 11/27/2024 and an end of care date of 12/12/2024, with a primary diagnosis of unspecified cirrhosis of the liver. During a record review of Patient 4s medical record form titled ";Comprehensive Nursing Assessment" dated 11/27/2024, indicated under section ";Referrals", Patient 3 was referred to the MSW and SC. Lastly, the form indicated it was electronically signed by RN1 on 11/27/2024. During a record review of Patient 4s medical record form titled ";History of Bereavement Assessment" undated, indicated there were no entries made. During a concurrent interview and record review on 1/8/2025 at 1:10 p.m. with the DPCS of Patient 4s electronic and physical medical record, the DPCS Patient 4 did not have a bereavement assessment.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to ensure the Condition of Participation for Organization and Administration of Services was met as evidenced by: --- 1. The HA failed to ensure volunteer services were offered and rendered for three of 14 sample patients (Patient 1, Patient 2, and Patient 3). (Refer to L652). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Organization and Administration of Services to ensure patients needs are met by qualified individuals.

Based on interview and record review the Hospice Agency (HA) failed to ensure one of fourteen sample patients (Patient 5) was provided with a comfort kit (medications and supplies used to help manage symptoms and feel comfortable) to facilitate their end-of-life process. This failure had the potential to result in causing pain and suffering to Patient 5 during the end of life process. --- During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 11/27/2024 and an end of care date of 12/12/2024 with a primary diagnosis of unspecified cirrhosis of the liver. During a record review of Patient 5s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 5s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. During a concurrent interview and record review on 1/7/2025 at 2:17 p.m., with Patient 5s daughter/caregiver, (CG2), CG2 stated Patient 5 was seen by RN1 once and no one else from the HA visited or called. CG2 stated Patient 5 passed away on 12/12/2024. CG2 stated Patient 5 never received anything from the HA. During a concurrent interview and record review on 1/8/2025 at 1:10 p.m., with the DPCS of Patient 5s electronic and physical medical record, the DPCS stated that the visiting nurse was supposed to provide Patient 5 a comfort kit. The DPCS stated that according to Patient 5s electronic and physical medical record, Patient 5 was not offered or provided with a comfort kit. The DPCS stated since Patient 5 did not receive a comfort kit, Patient 5 passed away painfully. The DPCS stated Patient 5s medication list did not include any pain medication.

Based on interview and record review the Hospice Agency (HA) failed to ensure volunteer services were offered and rendered for eight of 14 sample patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 12, and Patient 13). This failure had the potential to result in patients and their families/caregivers are not provided essential emotional and practical that cannot be covered by clinical staff alone. --- 12. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). A review of Patient 12s Electronic Medical Record (EMR) indicated that since Patient 12s recertification date of 11/4/2024, the Volunteer Coordinator (VC) did not submit or complete a volunteer assessment visit note. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the DD, Patient 12s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a a volunteer assessment/ visit note by the VC, and stated documentation should be submitted within 5 days of Patient 12s recertification date of 11/4/2024. The DD also stated it is important to provide the patient with volunteer services because the patient verbalized a need for it, and it is important for the VC to complete a volunteer assessment to identify the patients needs, like companionship, housekeeping, cooking, or errands. 13. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). A review of Patient 13s Electronic Medical Record (EMR) indicated that since Patient 13s recertification date of 10/31/2024, the VC did not submit or complete a volunteer assessment visit note. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m. with the DD, Patient 13s EMR and physical medical record were reviewed. The DD stated and verified there was no submission/completion of a volunteer assessment/ visit note by the VC, and stated documentation should be submitted within 5 days of Patient 13s recertification date of 10/31/2024. The DD stated it is important for all disciplines of the team like MSW, SC and VC to complete their assessment upon Patient 13s recertification to reassess the patients needs, safety of the home, their emotional and spiritual needs as well as the family/caregiver. 4. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). 5. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease with heart failure. 6. During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of COPD. During an interview on 1/6/2025 at 4:15 p.m. Administrator (ADM), the ADM stated the HA did not have volunteers on staff. During an interview on 1/8/2025 at 10:50 a.m. with Registered Nurse 1 (RN1), RN1 stated he determines when and if a patient requires volunteer services during their initial assessment. The RN1 stated he informs the ADM and the Director of Patient Care Services (DPCS) when he refers a patient for volunteer services. During an interview on 1/8/2025 at 11:41 a.m. with the DPCS, the DPCS stated the HA did not have a Volunteer Coordinator or volunteers. 1.During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). 2.During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 2 was referred to the MSW, SC, and Volunteer. Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the DD of Patient 2s electronic and physical medical record, the DD stated Patient 2s was not seen by a volunteer. DD stated there was nothing documented in Patient 2s medical record as to why he was not seen by a volunteer. The DD stated volunteers provide companionship and may be able to report any needs of the patients. 3.During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated under section ";Referrals", Patient 3 was referred to the MSW, SC, and Volunteer. Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s electronic and physical medical record, the DD stated Patient 3 was referred for volunteer services. The DD stated she was not aware if Patient 3 was seen by a volunteer because there was nothing documented in Patient 3s medical record.

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: Based on observation, interview, and record review, the Hospice (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA- a program that provides care and support for patients who are terminally ill and have stopped treatment to cure their disease) failed to ensure the Conditions of Participations (conditions that health care organizations must meet in order to begin and continue participating in the Medicare [a federal system of health insurance for people over 65 years of age and for certain younger people with disabilities]) regarding the Medical Director reviewing and documenting an accurate Certification of Terminal Illness (CTI- a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician) that reflected the patient's current health status and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness was met as follows: --- 1. The HA Medical Director 1 (MD1) failed to ensure to review and document an accurate CTI that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for 10 of 14 sampled active patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13). As a result of the noncompliance, Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13 were placed at increased risk for losing their hospice eligibility/hospice benefits, not receive hospice care when needed in the future, and had the potential to not receive the necessary care and services that could lead to potential hospitalization and death. (Refer to L667). 2. The HA 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 five of fourteen sampled patients (Patient 6, Patient 7, Patient 8, Patient 12, and Patient 13). (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 (a program that provides care and support for patients who are terminally ill [have six months of less to live] and have stopped treatment to cure their disease) Agency (HA, agency providing care to terminally ill patients who have six months or less to live) Medical Director 1 (MD 1) failed to ensure to review and document an accurate Certification of Terminal Illness (CTI-a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician) that reflected the patient's current health status and identify patients' need for hospice care and services related to hospice eligibility and management of terminal illness for 10 of 15 sample patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13) As a result of the noncompliance described above, Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13 were placed at increased risk for losing their hospice eligibility/hospice benefits, not receive hospice care when needed in the future, and had the potential to not receive the necessary care and services that could lead to potential hospitalization and death. On 1/10 /2025, at 3:54 p.m., the Department called an Immediate Jeopardy (IJ, a situation in which the facilitys noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient)IJ in the presence of the agencys Administrator(ADM) and Director of Patient Care Services (DPCS) related to failure to ensure the Medical Director 1 (MD1)MD 1 reviewed and documented a accurate Certification of Terminal IllnessCTI that reflected the patient's current health status and identify the patients' need for hospice care and services related to hospice eligibility and management of terminal illness for 10 of 15 sample patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13) On 1/10/2025, at 5:25 pm, the Department conducted an exit conference with the ADM and the DPCS with the IJ situation not removed. On 2/14/2025, at 10 am, the agency submitted an approved IJ removal plan (a plan to remove the IJ situation) as follow: 1.On 1/14/2025, the agency reviewed the CTIs of the active patients. 2.On 1/14/2025, the agency conducted in-services to the leadership and clinical staff including to the DPCS and Medical Director. 3.On 1/14/2025, the CTIs were corrected. 4.On 1/25/2025, the agency discharged Patient 2, Patient 3, Patient 12, and Patient 13. 5. On 1/25/2025, the Medical Director completed the CTIs for Patient 1, Patient 6, Patient 7, Patient 8, Patient 10, and Patient 11. On 2/14/2025, at 2:40 pm, the Department verified the IJ removal plan onsite and removed the IJ situation in the presence of the Administrator and the Director of Patient Care Services. --- 5. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease with heart failure. During a record review of Patient 7s medical record form, titled ";Physicians Order" dated 12/19/2024, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 7s medical record form titled ";LCD Hospice Eligibility Determination," dated 11/26/2024, it indicated Patient 7s qualifying factors included: 1. Patient optimally treated for heart disease with diuretics (medications that increase urine production to get rid of excess fluid) and vasodilators (medications that open blood vessels to increase blood flow to organs). 2. Patient meet the criteria for NYHA Class IV level. During a record review of Patient 7s medical record form, titled ";Physicians Certification for Hospice Benefit – Statement for First 90-day period," dated 11/26/2024, indicated RN 1 obtained verbal authorization from the MD 2, to admit Patient 7 for hospice services. The form indicated MD 2 did not sign the form. The form did not indicate if MD 2 wanted to follow Patient 7s care or not. Lastly, the form indicated, ";It is my clinical judgment that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice." During a record review of Patient 7s medical record form, titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for First 90-day period," dated 11/26/2024 to 2/23/2025, indicated Patient 7 ";has a life expectancy of 6 months or less, if the terminal illness, runs its normal course." The form also indicated, ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by MD 1 on 11/26/2024. During a record review of Patient 7s medical record form, titled ";Audit Log" dated from 11/26/2024 to 1/7/2025, indicated MD 1 signed Patient 7s CTI, dated 11/26/2024, on 12/13/2024. During a record review of Patient 7s medical record form, titled ";Comprehensive Nursing Assessment," dated 11/26/2024, the ";Comprehensive Nursing Assessment" indicated the following: 1. Patient 7 was alert; oriented to self, place, and time; and was able to verbalize needs and concerns. 2. Patient 7 had normal systolic blood pressure (SBP, measure of the force of blood pushing against artery walls during heart contraction with normal levels less than 120 mmHg) at 91-159. 3. Patient 7 had regular apical pulse (heart rate obtained by listening directly to the heartbeat using a stethoscope), pedal pulse (heart rate obtained by palpating the foot or using an ultrasound device) and radial pulse (heart rate obtained by palpating the radial artery of the wrist). 4. Patient 7 has no cardiac-related (heart-related) pain. 5. Patient 7 had a 2+ edema (slight swelling in the tissues due to fluid buildup with 4+ being most severe) to both lower extremities. 6. Patient 7 had mild dyspnea (SOB, shortness of breath) with mild exertion. 7. Patient 7 had normal respirations (breathing) with no cough. 8. Patient 7 ";required occasional assistance" but was able to care for most of his personal needs. During a concurrent interview and record review of Patient 7s medical records on 1/7/2024 at 2:14 PM with DD, Patient 7s ";Comprehensive Nursing Assessment," dated 11/26/2024, ";CTI," dated 11/26/2024, ";LCD Hospice Eligibility Determination," dated 11/26/2024, and physicians orders were reviewed. DD stated RN 1 documented that Patient 7 met the criteria for NYHA Class IV level but lacked documented evidence to support Patient 7s eligibility for hospice services. DD stated RN 1 conducted the initial home visit assessment for Patient 7 on 11/26/2024. DD stated Patient 7 was receiving hospice services without a physicians admission order. During an interview on 1/10/2025 at 1:41 PM, RN 1 stated he identified Patient 7 has NYHA Class IV level because Patient 7 had ";SOB after walking for a long time from the kitchen to the living room," had ";congested lungs," and had a ";history of chest pain and heart attack." RN 1 was unable to state the criteria in determining when a patient (in general) qualified for NYHA Class III or a Class IV level. RN 1 stated he did not review any medical records from Patient 7, HA 1, or from the hospital/clinic. During an interview on 1/10/2025 at 3:01 PM, ADM stated Patient 7 was referred by RP who ";worked at a clinic." ADM was unable to present any documented evidence of a referral from a clinic or a hospital that included Patient 7s medical records that supported Patient 7s eligibility to receive hospice services. 6. During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of COPD. During a record review of Patient 8s medical record form, titled ";Physicians Order" dated 12/11/2024, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 8s medical record form, titled ";LCD Hospice Eligibility Determination," dated 11/25/2024, it indicated Patient 8s qualifying factors included: 1. Poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. 2. Increasing visits to the emergency room, and 3. Hypoxemia (low level of oxygen in the blood) at rest on room air, as evidenced by pO2 (pO2, measure of the tension or pressure of oxygen dissolved in the blood obtained through a blood test or pulse oximetry) less than or equal to 55 millimeters of mercury (mmHG, unit of measurement of pressure). During a record review of Patient 8s medical record form, titled ";Physicians Certification for Hospice Benefit – Statement for First 90-day period," dated 11/25/2024, indicated RN 1 obtained verbal authorization from the MD 2 to admit Patient 8 for hospice services. The form indicated MD 2 did not sign the form. The form did not indicate if MD 2 wanted to follow Patient 8s care or not. Lastly, the form indicated, ";It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice." During a record review of Patient 8s medical record form, titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for First 90-day period," dated 11/25/2024 to 2/22/2025, indicated Patient 8 ";has a life expectancy of 6 months or less, if the terminal illness, runs its normal course." The form also indicated, ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by MD 1 on 11/25/2024. During a record review of Patient 8s medical record form, titled ";Audit Log" dated from 11/25/2024 to 1/7/2025, indicated MD 1 signed Patient 8s CTI, dated 11/25/2024, on 12/13/2024. During a record review of Patient 8s medical record form, titled ";Comprehensive Nursing Assessment," dated 11/25/2024, the ";Comprehensive Nursing Assessment" indicated the following: 1. Patient 8 was alert; oriented to self, place, and time; and was able to verbalize needs and concerns. 2. Patient 8 had episodes of severe SOB by walking to the front door of his house. 3. Patient 8 had moderate SOB with mild exertion, labored respirations with crackles (abnormal lung sounds) but no coughing. 4. Patient 8 was on oxygen therapy at 2 liters per minute via nasal cannula (thin, flexible tube that delivers supplement oxygen through the nose). 5. RN 1 did not document whether oxygen therapy was administered continuously or as needed. 6. RN 1 did not document Patient 8s oxygen saturation (amount of oxygen in the blood with normal values ranging from 95% to 100% that could be obtained via pulse oximetry (non-invasive method that measures the amount of oxygen in the blood). During a concurrent interview and record review of Patient 8s medical records on 1/7/2024 at 2:14 PM with DD, Patient 8s ";Comprehensive Nursing Assessment," dated 11/25/2024, ";CTI," dated 11/25/2024, ";LCD Hospice Eligibility Determination," dated 11/25/2024, and physicians orders were reviewed. DD stated DD stated RN 1 documented Patient 8 had ";hypoxemia at rest on room air, but there was no documented evidence of pO2 in Patient 8s medical records. DD stated RN 1 conducted the initial home visit assessment for Patient 8 on 11/25/2024. DD stated Patient 8 was receiving hospice services without a physicians admission order. During an interview on 1/10/2025 at 1:41 PM, RN 1 stated he did not review any medical records from Patient 8, HA 1, or from the hospital/clinic. During an interview on 1/10/2025 at 3:01 PM, ADM stated Patient 8 was referred by RP who ";worked at a clinic." ADM was unable to present any documented evidence of a referral from a clinic or a hospital that included Patient 8s medical records that supported Patient 8s eligibility to receive hospice services. 7. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). A review of Patient 10s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 10s medical record form titled ";LCD Hospice Eligibility Determination" dated 11/19/2024, indicated Patient 10s qualifying factors included 1c. patient optimally treated for heart disease with diuretics and vasodilators, 2a. the CHF or angina patient meets the criteria for NYHA Class IV level, and 3d. brain embolism of cardiac origin. A review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefit- Statement for first 90-day period" dated 11/19/2024, indicated Registered Nurse 1 (RN 1) obtained verbal authorization from the Medical Director 2 (MD 2) to admit Patient 10 for hospice services. The form also indicated it was not signed by the MD2and it did not state if MD2 wanted to follow Patient 10s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 11/19/2024 to 2/16/2025, indicated ";Given her comorbidities and terminal diagnosis, she qualifies for hospice care to manage symptoms and provide comfort. Certification for hospice care is recommended based on her terminal condition and current functional status." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 11/19/2024. A review of Patient 10s medical record form titled ";Audit Log" dated from 11/1/2024 to 1/7/2025, indicated MD1 signed Patient 10s CTI dated 11/19/2024 on 12/13/2024. During a review of Patient 10s medical record form titled ";Comprehensive Nursing Assessment" dated 11/19/2024, indicated Patient 10 had edema with a pitting level of 1 but did not indicate the location. The form indicated RN1s narrative documentation included Patient 10s co-morbidities including arthritis (joint pain), diabetes (high blood sugar), history of pancreatic cancer (cancer to the pancreas), post breast cancer, one kidney removal, Parkinsons tremors (a brain disorder that causes movement problems including tremors), history of heart attack, asthma (chronic lung disease that causes airways to narrow and swell, making it hard to breathe), history of depression (mental health condition that involves constant low mood and loss of interest) and schizophrenia (chronic mental illness that affects a persons thoughts, feelings and behaviors). RN1s documented narrative also indicated, ";Hospice philosophy and services were discussed in detail. Roles and responsibilities of the interdisciplinary Team has been reviewed. Educate the family/caregiver the importance of following all medication regimen, proper diet and safety from fall and infection... Caregiver verbalized understanding to all teaching." Lastly, the form indicated it was electronically signed by RN1 on 11/19/2024. During a concurrent interview and record review on 1/7/2025 at 3:4 p.m. with the Director of Patient Care Services Designee (DD), Patient 10s Electronic Medical Record (EMR) and physical medical record were reviewed. The DD stated Patient 10 was referred by MD2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 10 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 10s medical records did not contain her history and/or physical, or hospital records therefore, the Hospice Agency (HA) does not have any evidence to support Patient 10s documented LCD. During a phone interview on 1/8/2025 at 1:45pm with Patient 10s Caregiver (CG1), CG1 stated Patient 10 lives alone in an apartment and is alert and oriented to self and time and is forgetful. CG1 stated she has been caring for Patient 10 since 8/11/2022 and assists her with baths, cooking, cleaning the apartment, and medication administration. CG1 also stated Patient 10 does have a primary physician who Patient 10 continues to see, and the primary physician did not refer Patient 10 nor is aware of the hospice services Patient 10 is receiving. CG1 also stated the hospice agencys Administrator (ADM) came to Patient 10s apartment and signed her up for hospice services and did not explain what hospice services were. During a concurrent interview and record review on 1/10/2025 at 11:54 a.m. with the Director Of Patient Care Services (DPCS), Patient 10s EMR and physical medical record were reviewed. The DPCS stated Patient 10 does not have any treatment orders. The DPCS stated the HA did not have Patient 10s history and physical, or any documented evidence that supports the admitting nurses assessment. The DPCS stated there were no physical documents to attest to Patient 10s assessment. The DPCS further stated it is important to have supporting evidence because it supports what is being documented by the SN and objective data is needed to verify patient eligibility for hospice services. 8. A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). A review of Patient 11s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 11s medical record form titled ";LCD Hospice Eligibility Determination" dated 11/6/2024, indicated Patient 11s qualifying factors included 1a. patient has been ruled out as a candidate for surgical procedures, 1b. patient has declined surgical procedures, 1c. patient optimally treated for heart disease with diuretics and vasodilators, 2a. the CHF or angina patient meets the criteria for NYHA Class IV level, and 3b. has history of cardiac arrest or resuscitation. A review of Patient 11s medical record form titled ";Physicians Certification for Hospice Benefit- Statement for first 90-day period" dated 11/6/2024, indicated the Skilled Nurse (SN) obtained verbal authorization from the Medical Director 2 (MD 2) to admit Patient 11 for hospice services. The form also indicated it was not signed by the MD2 and it did not state if MD2 wanted to follow Patient 11s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 11s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 11/6/2024 to 2/3/2025, indicated ";Due to the progression of atherosclerotic heart disease, worsening comorbidities, and overall decline in health, the patient meets LCD eligibility for hospice care." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 11/6/2024. A review of Patient 11s medical record form titled ";Audit Log" dated from 11/1/2024 to 1/7/2025, indicated MD1 signed Patient 11s CTI dated 11/6/2024 on 11/17/2024. During a review of Patient 11s medical record form titled ";Comprehensive Nursing Assessment" dated 11/6/2024, indicated Patient 11 had apical pulse, pedal pulse, and radial pulse irregular and weak. The form indicated the SNs narrative documentation included Patient 11s co-morbidities including type 1 diabetes (high blood sugar), hypertension (high blood pressure), hyperlipidemia (high cholesterol). The SNs documented narrative also indicated, ";Hospice philosophy, disease progression, symptom management, and comfort care reviewed with the patient and PCG... Consent forms were signed, and PCG was informed of 24-hour hospice support availability." Lastly, the form indicated it was electronically signed by the SN on 11/6/2024. During a concurrent interview and record review on 1/7/2025 at 4:00 p.m. with the Director of Patient Care Services Designee (DD), Patient 11s Electronic Medical Record (EMR) and physical medical record were reviewed. The DD stated Patient 11 was referred by MD2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 11 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 11s medical records did not contain her history and/or physical, or hospital records therefore, the Hospice Agency (HA) does not have any evidence to support Patient 11s documented LCD. During a phone interview on 1/8/2025 at 12:19pm with Patient 11, Patient 11 stated he was not referred to hospice services but was approached by a lady from the HA on the street and offered in home services for a nurse to visit him weekly and provide him with medication and refills. Patient 11 stated he has a primary physician who he continues to see and is not aware of the services he is receiving from the HA. Patient 11 stated he has a left below the knee amputation and moves around in a scooter, but is able to care for himself, cook, wash, and go out in his wheelchair. Patient 11 further stated he was not explained what hospice services were by the SN and has never been told by his primary physician that he has a terminal illness. During a joint home visit on 1/9/2025 at 1:30pm at Patient 11s home, Patient 11 was observed not to be home and Patient 11s sister stated Patient 11 likes to get out of the house on his scooter. During a concurrent interview and record review on 1/10/2025 at 11:54 a.m. with the Director Of Patient Care Services (DPCS), Patient 11s EMR and physical medical record were reviewed. The DPCS stated Patient 11 does not have any treatment orders. The DPCS stated the HA did not have Patient 11s history and physical, or any documented evidence that supports the admitting nurses assessment. The DPCS stated there were no physical documents to attest to Patient 11s assessment. The DPCS further stated it is important to have supporting evidence because it supports what is being documented by the SN and objective data is needed to verify patient eligibility for hospice services. 9. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). A review of Patient 12s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 12s medical record form titled ";LCD Hospice Eligibility Determination" dated 11/4/2024, indicated Patient 12s qualifying factors included 1a. a Karnofsky performance status of less than or equal to seventy, 1b. a palliative performance status of less than or equal to seventy, and 2b. pyelonephritis in the past 12 months. A review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefit- Statement for first 90-day period" dated 8/6/2024, indicated Registered Nurse 1 (RN 1) obtained verbal authorization from the Medical Director 2 (MD 2) to admit Patient 12 for hospice services. The form also indicated it was not signed by the MD2 and it did not state if MD2 wanted to follow Patient 12s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #2: Statement for second 90-day period" dated 11/4/2024 to 2/1/2025, indicated ";Due to the patients poor prognosis, worsening comorbidities, and ongoing decline, the patient and family have opted to continue hospice care for comfort measures. The patient meets LCD eligibility criteria for the second benefit period." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 11/4/2024. A review of Patient 12s medical record form titled ";Audit Log" dated from 8/1/2024 to 1/7/2025, indicated MD1 signed Patient 12s CTI dated 11/4/2024 on 11/17/2024. During a review of Patient 12s medical record form titled ";Re-Cert Assessment" dated 11/4/2024, indicated Patient 12s neurological/mental/sensory symptom/demeanor is peaceful, level of consciousness is awake and alert, and oriented to time and person. The form indicated the DPCS narrative documentation included Patient 12s co-morbidities including hypertension (high blood pressure), benign prostatic hyperplasia (BPH, noncancerous enlargement of the prostate gland), and hyperlipidemia (high cholesterol). The DPCS documented narrative also indicated, ";Due to patients poor prognosis, worsening comorbidity and declining condition, patient and family have now opted for hospice care for comfort measures, symptom management and comfort care only. Patient is appropriate for hospice care for the 2nd benefit period per MD order, meeting the criteria for the LCD eligibility." Lastly, the form indicated it was electronically signed by the DPCS on 11/4/2024. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the Director of Patient Care Services Designee (DD), Patient 12s Electronic Medical Record (EMR) and physical medical record were reviewed. The DD stated Patient 12 was referred by MD2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 12 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 12s medical records did not contain her history and/or physical, or hospital records therefore, the Hospice Agency (HA) does not have any evidence to support Patient 12s documented LCD. During a concurrent interview and record review on 1/10/2025 at 11:54 a.m. with the Director Of Patient Care Services (DPCS), Patient 12s EMR and physical medical record were reviewed. The DPCS stated Patient 12 does not have any treatment orders. The DPCS stated and verified she completed Patient 12s recertification assessment dated 11/4/2024 and did not receive any hospital documents, images or copy of history and physical from the patient during recertification assessment visit. The DPCS stated the HA did not have Patient 12s history and physical, or any documented evidence that supports her recertification assessment. The DPCS stated there were no physical documents to attest to Patient 12s assessment. The DPCS further stated it is important to have supporting evidence because it supports what is being documented by the SN and objective data is needed to verify patient eligibility for hospice services. 10. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). A review of Patient 13s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. A review of Patient 13s medical record form titled ";LCD Hospice Eligibility Determination" dated 10/31/2024, indicated Patient 13s qualifying factors included 1c. patient optimally treated for heart disease with diuretics and vasodilators, 2a. the CHF or angina patient meets the criteria for NYHA Class IV level, 3b. has history of cardiac arrest or resuscitation, and 3c. has history of unexplained syncope/fainting. A review of Patient 13s medical record form titled ";Physicians Certification for Hospice Benefit- Statement for first 90-day period" dated 8/2/2024, indicated Registered Nurse 1 (RN 1) obtained verbal authorization from the Medical Director 2 (MD 2) to admit Patient 13 for hospice services. The form also indicated it was not signed by the MD2 and it did not state if MD2 wanted to follow Patient 13s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 13s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for Second 90-day period" dated 10/31/2024 to 1/28/2025, indicated ";Hospice Medical Director has certified for the 2nd benefit period that the patient has a terminal illness with a life expectancy of six months or less if the disease process will take its normal course." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 10/31/2024. A review of Patient 13s medical record form titled ";Audit Log" dated from 8/1/2024 to 1/7/2025, indicated MD1 signed Patient 13s CTI dated 10/31/2024 on 11/17/2024. During a review of Patient 13s medical record form titled ";Re-cert Assessment" dated 10/312024, indicated Patient 13 had edema with a pitting level of 2 but did not indicate the location. The form indicated the DPCSs narrative documentation included Patient 13s co-morbidities including hypertension (high blood pressure), and arthritis (joint pain). The DPCSs documented narrative also indicated, ";Hospice Medical Director has certified for the 2nd benefit period that the patient has a terminal illness with a life expectancy of six months or less if the disease process will take its normal course." Lastly, the form indicated it was electronically signed by the DPCS on 10/31/2024. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m. with the Director of Patient Care Services Designee (DD), Patient 13s Electronic Medical Record (EMR) and physical medical record were reviewed. The DD stated Patient 13 was referred by MD2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 13 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 13s medical records did not contain her history and/or physical, or hospital records therefore, the Hospice Agency (HA) does not have any evidence to support Patient 13s documented LCD. During a concurrent interview and record review on 1/10/2025 at 11:54 a.m. with the Director Of Patient Care Services (DPCS), Patient 13s EMR and physical medical record were reviewed. The DPCS stated Patient 13 does not have any treatment orders. The DPCS stated and verified she completed Patient 13s recertification assessment dated 10/31/2024 and did not receive any hospital documents, images or copy of history and physical from the patient during recertification assessment visit. The DPCS stated the HA did not have Patient 13s history and physical, or any documented evidence that supports her recertification assessment. The DPCS stated there were no physical documents to attest to Patient 13s assessment. The DPCS further stated it is important to have supporting evidence because it supports what is being documented by the SN and objective data is needed to verify patient eligibility for hospice services. During a record review of the HAs form titled ";Job Description – Professional Services Agreement Medical Director" revised April 2019, indicated ";Medical Director will review and sign initial hospice certifications of terminal illness, and recertification as indicated." During a record review of the HAs form titled ";Job Description – Clinical Director/Director of Patient Care Services" revised April 2019, indicated ";The Clinical Director/Director of Patient Care Services is responsible for the overall direction of hospice clinical services. Coordinates and oversees all direct and indirect patient services provided by clinical organization personnel. During a record review of the HAs form titled ";Job Description – executive Director/Administrator" revised April 2019, indicated ";The executive Director/Administrator is responsible for the overall direction of the hospice services. Ensuring organizational compliance with legal, regulatory and accreditation requirements." During a record review of the HAs form titled ";Admission Criteria and Process" revised April 2019, indicated ";(HA) will admit any patient with a life-limiting illness that meets the admission criteria. The patients life-limiting and prognosis of six (6) months or less will be determined by utilizing standard clinical prognosis criteria developed by the fiscal intermediarys Local Coverage Determinations (LCDs)." During a record review of the HAs form titled ";Certification of terminal Illness" revised April 2019, indicated ";When certifying the patient as terminally ill the hospice Medical Director must consider at least the diagnosis of the terminal condition of the patient, other health conditions, whether related or not to the terminal condition, and current relevant information supporting the diagnosis. Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the clinical record with the written certification. Both the attending physicians and Medical Directors signed and dated initial certification forms must be on file prior to billing the first claim. Tools such as the fiscal intermediarys Local Coverage Determinations, along with other supporting documentation, can be used to provide guidance in determining and documenting terminal prognosis." During a record review of the HAs form titled ";Initial Assessment" revised April 2019, indicated ";Admitting registered nurse will gather the following information: orders for specific hospice services and disciplines, treatments, and procedures." During a record review of the HAs form titled ";Verification of Physician Orders" revised April 2019, indicated ";Orders will be obtained from a licensed physician for care and services to be provided to hospice patients. A qualified individual will review each order or prescription before care is provided. During an interview on 1/8/2025 at 11:21 a.m. with the Medical Director 2 (MD2), MD 2 stated he does not work for or has heard of the HA. MD2 stated he is not the HAs referring physician. MD2 stated he does not work in Los Angeles County. During an interview on 1/8/2025 at 11:41 a.m. with the DPCS, the DPCS stated the HA did not have any history or physical documentation for any of their patients. The DPCS stated all their patients were referred by MD2. The DPCS stated she has not attempted to contact MD2 but that the Administrator (ADM) has. The DPCS stated she reviews and bases her documentation on the admitting nurses initial assessment documentation. During an interview on 1/8/2025 at 12:33 p.m. with the ADM, the ADM stated MD2 was the referring physician and was responsible for giving and signing the patients admitting orders. The ADM states he last spoke with the MD2 about a month ago. During an interview on 1/10/2025 at 10 a.m. with the Medical Director 1 (MD1), MD1 stated he has been the Medical Director for the HA since 2023. The MD1 stated his duties included coordinating patients medical care. MD1 stated MD2 was the referring MD who worked with the HA before he was the MD1 but has never met him. During an interview on 1/10/2025 at 10 a.m. with MD1, MD1 stated he was unable to log into the HAs patients Electronic Medical Record (EMR) due to power outage at his current location. MD1 stated he recommends the HA to obtain the needed patient records before the initial nursing home visit assessment to determine if the patient qualifies for hospice services. MD1 stated the HA receives the referring physicians orders and the patients information before the initial home visit is performed. MD1 stated when the HA has no information on a patient to go by, they send a nurse to evaluate the patient. MD1 stated the DPCS provides him all the patients information which he uses to determine if the patient qualifies for hospice services or not. MD1 stated, ";We doctors try to check what fits to qualify the patient to hospice. Usually, I get the information from the DPCS...". During an interview on 1/10/2025 at 10 a.m. with the MD1, MD1 stated he uses the Local Coverage of Determination (LCD-a tool used to determine if a patient meets hospice care based on specific criteria). MD1 stated the Director of Patient Care Services (DPCS) fills out the patients LCD based on their assessment. MD1 stated the patients Certification for Terminal Illness (CTI - a document that certifies the patient for hospice care by a doctor), he composes, and sign are based on the information provided by the referring physician, the patients medical history, and the visiting nurse assessment. MD1 stated patients CTI are to be composed and signed as soon as they are posted, but sometimes he signs them late. MD1 stated his signature on the patients CTI indicates he authenticated, composed, and signed the form. During an interview on 1/10/2025 at 10:20 a.m. with MD1, MD1 stated he has not seen or spoken to any HAs patients so far. MD1 stated he has not read any patients history and physicals. MD1 stated the DPCS provides verbal patient information to him which he uses to composes the physician narrative on the patients CTI. During an interview on 1/10/2025 at 10:20 a.m. with the MD1, MD1 stated he dictates patients orders to the DPCS. MD1 stated patients routine admission orders include admit to hospice care, all their medications to be continue, treatment orders. During an interview on 1/10/2025 at 11:57 AM, the DPCS stated the Administrator, who was not a licensed nurse or physician, was responsible for determining a patients (in general) eligibility for hospice services. The DPCS stated she has not communicated with the referring physician or healthcare facility to request for the patients (in general) medical records to determine and support hospice eligibility. The DPCS stated she ";assumed" the Administrator had requested the medical records prior to the patients (in general) admission to HA 1. The DPCS stated she reviewed the hospice eligibility based on the admitting Registered Nurses ";Comprehensive Nursing Assessment." During an interview on 1/10/2025 at 1:41 PM, Registered Nurse 1 (RN 1) stated the Administrator would inform RN 1 if a patient (in general) would be admitted to HA 1. RN 1 stated HA 1 would provide the patients name, address, and complaints. RN 1 stated he conducted his ";Comprehensive Nursing Assessment" based on the patients (in general) and/or caregivers responses. RN 1 stated he did not review the patients (in general) medical records from the hospital or any documentation from any healthcare facility. During an interview on 1/10/2025 at 3 p.m. with the ADM, the ADM stated all the current active HA patients referrals were received from clinics, hospitals, and some personal. The ADM then stated the active patients were referred from the Referral Person (RP) who works for a clinic. The ADM stated he request patients medical records and admitting orders from the referring physician but has not contacted the referring physician for patients admitted within a month. The ADM stated MD2 is a mobile doctor and has four Nurse Practitioners working under him. The ADM stated he sends Nurse Practitioner 1 (NP1) patients information because NP1 is responsible for writing the patients admitting orders. The ADM was unable to provide NP1s phone number when requested. During an interview on 1/10/2025 at 3:01 PM, the Administrator (ADM)stated he reviewed all patient referrals. ADM stated he obtained his patient referrals from the ";clinics, hospitals, and personal referrals." ADM stated Patient 6 was referred by Referral Person (RP) who ";worked at a clinic." ADM was unable to present any documented evidence of a referral from a clinic or a hospital that included Patient 6s medical records that supported Patient 6s eligibility to receive hospice services. During an interview on 1/10/2025 at 3:37 p.m. with the Referral Person (RP), RP stated she is a licensed medical social worker that works for a non-profit organization that assist in referring inpatients, outpatient, persons in drug rehab and shelters from one program to another. The RP stated she contacts the programs to let them know when a person is interested but that it is up to the program to admit or not. During an interview on 1/10/2025 at 3:37 PM, RP stated she worked at a ";non-profit organization that handles referrals" to different agencies for individuals from drug rehabilitation centers, shelters, crisis centers, and/or for those at risk for suicide. RP stated she did not work directly for HA 1. RP stated she would ";begin the process" by sending out referrals but would not make the determination for eligibility for services. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). The form also listed MD2 as Patient 1s referring/attending/patient choice. During a record review of Patient 1s medical record form titled ";Physician Order" dated 1/4/2025, did not indicate there was a physician admission order for hospice services order. During a record review of Patient 1s medical record form titled ";LCD Hospice Eligibility Determination" dated 12/13/2024, indicated Patient 1s qualifying factors included 1. Poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. 2. Increased visit to the emergency room. 3. Oxygen saturation less than or equal to 88% determined either by arterial blood gases or oxygen saturation monitors (these values may be obtained from recent hospital records) and 4. Unintentional progressive weight loss > or = 10% of body weight over last six months. During a record review of Patient 1s medical record form titled ";Physicians Certification for Hospice Benefit – Statement for first 90-day Period" dated 12/13/2024, indicated Registered Nurse 1 (RN1) obtained verbal authorization from the MD2 to admit Patient 1 for hospice services. The form also indicated it was not signed by MD2 and it did not state if MD2 wanted to follow Patient 1s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 1s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 12/13/2024 to 3/12/2025, indicated ";In my professional opinion that the patient has a prognosis of less than six months based on his current clinical condition and the trajectory of his illness." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by MD1 on 12/16/2024. During a record review of Patient 1s medical record form titled ";Audit Log" dated from 11/26/2024 to 1/7/2025, indicated MD1 signed Patient 1s CTI dated 12/13/2024 on 12/20/2024. During a record review of Patient 1s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 1s oxygen saturation was at 96%, but it does not indicate if his oxygen reading was with oxygen or not. The form also indicated Patient 1 was receiving oxygen at 2 liters per minutes via a nasal cannula. The form did not indicate who Patient 1s caregiver was. The form indicated RN1s narrative documentation included Patient 1s co-morbidities including diabetes (high blood sugar), arthritis (joint pain), scoliosis (abnormal spine curvature), and hypertension (high blood pressure). RN1s documented narrative also included ";The patients caregiver verbalized understanding regarding the Election of Hospice Benefits and elected MD as the attending physician... The patients current condition, medication, and treatments have been recorded and reviewed with MD via telephone and ordered to continue the medications and treatments upon admission." Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m. with the Director of Patient Care Services Designee (DD) of Patient 1s EMR and physical medical record, the DD stated Patient 1s start of care date was 12/13/2024. The DD stated Patient 1 was referred by MD2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 1 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 1 was receiving oxygen from the HA without a physicians order. The DD stated Patient 1s medical records did not contain his history and/or physical, therefore, the HA does not have any evidence to support Patient 1s documented LCD. During an interview on 1/8/2025 at 7:57 a.m. with Patient 1, Patient 1 stated he was not receiving hospice services. Patient 1 stated he was not a hospice patient and that he wants ";to live a little bit longer". Patient 1 stated he had never heard of RN1s name. During an interview on 1/8/2025 at 10:50 a.m. with RN1, RN1 stated he conducted Patient 1s initial assessment on 12/13/2025 and has seen Patient 1 for two or three visits. RN1 stated requesting Patient 1s primary physician medical records from Patient 1 and from the HAs ADM and DPCS. RN1 stated he spoke with MD2 about Patient 1 at which time he received verbal orders from MD2. RN1 was unable to provide MD2s phone number. During a concurrent interview and record review on 1/8/2025 at 12:10 p.m. with the DPCS of Patient 1s EMR and physical medical record, the DPCS stated RN1 provided Patient 1s initial home visit assessment on 12/13/2024. The DPCS stated Patient 1 is receiving hospice services without a physician admission order. During an interview on 1/8/2025 at 12:35 p.m. with the ADM of Patient 1s EMR and physical medical record, the ADM stated MD2 was Patient 1s referring doctor and needed to sign the admitting orders. During a concurrent interview and record review on 1/8/2025 at 12:35 p.m. with the DPCS of Patient 1s EMR and physical medical record, the DPCS stated Patient 1 does not have any treatment orders. The DPCS stated it was important to have completed patient documents for liability reasons. The DPCS stated the HA did not have Patient 1s history and physical, or any documented evidence that supports the admitting nurses assessment. The DPCS stated there were no physical documents to attest to Patient 1s assessment. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). The form also listed MD2 as Patient 2s referring/attending/patient choice. During a record review of Patient 2s medical record form titled ";Physician Order" dated 12/19/2024, did not indicate there was a physician admission order for hospice services order. During a record review of Patient 2s medical record form titled ";LCD Hospice Eligibility Determination" dated 12/13/2024, indicated Patient 2s qualifying factors included 1. Is patient optimally treated for heart disease with diuretics and vasodilators. 2. Does this CHF or angina patient meet the criteria for New York Heart Association (NYHA – a system for categorizing the severity of heart failure based on a patients physical activity limitations) Class IV (unable to carry out any physical activity without discomfort) level. During a record review of Patient 2s medical record form titled ";Physicians Certification for Hospice Benefit – Statement for first 90-day Period" dated 12/13/2024, indicated RN1 obtained verbal authorization from the MD2 to admit Patient 2 for hospice services. The form also indicated it was not signed by MD2 and it did not state if MD2 wanted to follow Patient 2s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 2s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 12/13/2024 to 3/12/2025, indicated Patient 2 co morbidities include arthritis, diabetes, chronic back pain, and depression. The form also indicated Patient 2 suffers from dyspnea, chest pain and reduced capacity for physical activity, and discomfort even at rest. The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by MD1 on 12/16/2024. During a record review of Patient 2s medical record form titled ";Audit Log" dated from 12/15/2024 to 1/7/2025, indicated MD1 signed Patient 2s CTI dated 12/13/2024 on 12/26/2024. During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 2 was alert, oriented and able to verbalize pain, and that Patient 2 stated he was not uncomfortable due to pain at that time. The form also indicated Patient 2 required moderate assistance with ambulation, toileting, dressing, feeding, and bathing and was complete dependent when transferring. The form also indicated Patient 2 had a NYHA class level of IV. The form also indicted under the Cardiovascular section that Patient 2 had a regular pulse rate, and had +1 pitting level edema, but it does not state where the pitting edema was located. Section ";cardiac-related pain" under Cardiovascular was left blank. The form indicated RN1s narrative documentation included Patient 1s co-morbidities including diabetes, arthritis, depression, and open-heart surgery. RN1s documented narrative also included ";Patient with cardiac disease resulting in inability to carry on any physical activity without discomfort." Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the DD of Patient 2s EMR and physical medical record, the DD stated Patient 2s start of care date was 12/13/2024. The DD stated Patient 2 was referred by MD2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 2 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 2s medical records did not contain his history and/or physical, therefore, the HA does not have any evidence to support Patient 2s documented LCD. During an interview on 1/8/2025 at 8:12 a.m. with Patient 2, Patient 2 stated he was not dying, and that no one ever told him he was dying. Patient 2 stated he was referred by a friend of a friend, who also told him that he would get nutrition supplement and a blood sugar reading machine. Patient 2 stated he sees had a cardiologist and a primary doctor (MD3). Patient 2 stated I am not dying, only God knows when Ill die. During an interview on 1/8/2025 at 10:45 a.m. with License Vocational Nurse 1 (LVN1), LVN1 stated she visited Patient 2 twice. LVN1 stated she does not follow Patient 2s plan of care because she does not have it. LVN1 stated she checks Patient 3s blood pressure, ask when his last bowel movement was, if he is experiencing any medication side effects, if he had any falls, how his sleeping and appetite are, and if there are any changes to report. LVN1 stated Patient 3 can ambulate by himself but should use a walker. LVN1 stated Patient 3 can eat, transfer, and able to use restroom by himself. LVN1 stated Patient 3 will be seeing his primary physician either in March or April 2025. During an interview on 1/8/2025 at 11 a.m. with MD3, MD3 stated she was Patient 2s primary physician. MD3 stated she last saw Patient 2 on 11/14/2024 . MD3 stated she did not refer Patient 2 for hospice services. MD3 stated Patient 2 has chronic illnesses but is a ";pretty healthy man". During a concurrent interview and record review on 1/8/2025 at 12:45 p.m. with the DPCS of Patient 2s EMR and physical medical record, the DPCS stated RN1 documented Patient 2s LCD form incorrectly. The DPCS stated Patient 2 was not taking diuretics (medication to eliminate water from body). 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. The form also listed MD2 as Patient 3s referring/attending/patient choice. During a record review of Patient 3s medical record form titled ";Physician Order" dated 12/19/2024, did not indicate there was a physician admission order for hospice services order. During a record review of Patient 3s medical record form titled ";LCD Hospice Eligibility Determination" dated 12/13/2024, indicated Patient 3s qualifying factors included 1. Poorly responsive or unresponsive to bronchodilators, resulting in decreased functional capacity. 2. Documentation of Forced Expiratory Volume in one Second (FEV1) after bronchodilator, less than 30% of predicted. 3. Increased visit to the emergency room and 4. Oxygen saturation less than or equal to 88% determined either by arterial blood gases or oxygen saturation monitors (these values may be obtained from recent hospital records). During a record review of Patient 3s medical record form titled ";Physicians Certification for Hospice Benefit – Statement for first 90-day Period" dated 12/13/2024, indicated Registered Nurse 1 (RN1) obtained verbal authorization from the MD2 to admit Patient 3 for hospice services. The form also indicated it was not signed by MD2 and it did not state if MD2 wanted to follow Patient 3s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 3s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 12/13/2024 to 3/12/2025, indicated ";This patients terminal diagnosis of COPD is accompanied by significant comorbidities and functional decline. Her symptoms including shortness of breath, pain and edema are being addressed with ongoing hospice care. Her prognosis is poor, and hospice care remains appropriate for symptom management and comfort care." Lastly, the form indicated it was electronically signed by MD1 on 12/16/2024. During a record review of Patient 3s medical record form titled ";Audit Log" dated from 12/1/2024 to 1/7/2025, indicated MD1 signed Patient 3s CTI dated 12/13/2024 on 12/26/2024. During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Patient 3s oxygen saturation was at 97%, but it does not indicate if her oxygen reading was with oxygen or not. The form also indicated Patient 3 was not receiving oxygen. The form also indicated Patient 3 required moderate assistance with toileting, dressing, feeding, and bathing and was complete dependent when transferring and ambulating. The form also indicated under the Cardiovascular section that Patient 3 had a regular pulse rate, and had +2 pitting level edema, but it does not state where the pitting edema was located. Section ";cardiac-related pain" under Cardiovascular indicated ";no". The form indicated RN1s narrative documentation included Patient 3s co-morbidities including diabetes, arthritis, gastritis (stomach pain) and osteoporosis (weak and brittle bones). RN1s documented narrative also included ";The patients caregiver verbalized understanding regarding the Election of Hospice Benefits and elected MD as the attending physician... The patients current condition, medication, and treatments have been recorded and reviewed with MD via telephone and ordered to continue the medications and treatments upon admission." Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a record review of Patient 3s Center for Medical and Medicare (CMS) form 807 (form used by a California Department of Public Health (CDPH) employee to document any interview, observation, or record review of a patient during a survey and/or investigation), Patient 3s CMS form 807 was completed by CDPH Employee 1 (CDPH1), CDPH1 documented she visited Patient 3 on 1/9/2025. CDPH1 documented Patient 3 did not know she was sick and did not know she required hospice services. CDPH1 documented Patient 3 stated License Vocational Nurse 1 (LVN1) visits every two weeks. CDPH1 documented Patient 3 has a primary physician (MD4) who she will see on 1/17/2025. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s EMR and physical medical record, the DD stated Patient 3s start of care date was 12/13/2024. The DD stated Patient 3 was referred by MD2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 3 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated an admission order is needed to be to know the medical history of the patient and be able to coordinate care if needed with the referring doctor and to sign off for hospice care and the recommended care for the patient. The DD stated Patient 3 was not receiving oxygen from the HA. The DD stated Patient 3s medical records did not contain her history and/or physical, therefore, the HA does not have any evidence to support Patient 3s documented LCD. During a concurrent interview and record review on 1/8/2025 at 1 p.m. with the DPCS of Patient 3s EMR and physical medical record, the DPCS stated RN1 provided Patient 3s initial home visit assessment on 12/13/2024. The DPCS stated Patient 3 is receiving hospice services without a physician admission or treatment orders. The DPCS stated Patient 3s medical record did not contain documented evidence to support RN1s documentation. During an interview on 1/8/2025 at 10:45 a.m. with LVN1, LVN1 stated she visits Patient 3 and Patient 3s sister at their home every other week. LVN1 stated Patient 3 might have a walker (a walking assistive device), but she did not see it while doing a home visit. 4. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (progressive memory loss). During a record review of Patient 6s medical record form titled ";Physicians Order" dated 1/4/2025, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 6s medical record form titled ";LCD Hospice Eligibility Determination," dated 12/12/2024, indicated Patient 6 did not qualify per LCD guidelines. The ";LCD Hospice Eligibility Determination" indicated Patient 6 did not meet the following qualifying factors: 1. Unable to dress without assistance. 2. Unable to bathe without assistance. 3. Urinary and fecal incontinence (inability to voluntary control urine or bowel movement) is intermittent or constant/dependent on catheter (thin, flexible tube that can be inserted into the body) or ostomy (surgical opening in the body to help remove waste) care. 4. Unable to consistently have meaningful verbal communication; utters stereotypical phrases only, or ability to speak six or fewer intelligible words. The ";LCD Hospice Eligibility Determination" indicated Patient 6 had inability to maintain sufficient fluid and calorie intake with 10% weight loss during the previous 6 months or serum albumin (laboratory test that measures the protein in the blood that helps maintain fluid balance) was less than 2.5 grams per deciliter. During a record review of Patient 6s medical record form, titled ";Physicians Certification for Hospice Benefit – Statement for First 90-day period," dated 12/12/2024, indicated RN 1 obtained verbal authorization from the MD 2 to admit Patient 6 for hospice services. The form indicated MD 2 did not sign the form. The form did not indicate if MD 2 wanted to follow Patient 6s care or not. Lastly, the form indicated, ";It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice." During a record review of Patient 6s medical record form, titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for First 90-day period," dated 12/12/2024 to 3/11/2025, indicated Patient 6 ";has a life expectancy of 6 months or less, if the terminal illness, runs its normal course." The form also indicated, ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by MD 1 on 12/13/2024. During a record review of Patient 6s medical record form titled ";Audit Log" dated from 12/12/2024 to 1/7/2025, indicated MD 1 signed Patient 6s CTI dated 12/12/2024 on 3/11/2025 on 12/26/2024. During a record review of Patient 6s medical record form, titled ";Comprehensive Nursing Assessment," dated 12/12/2024, the ";Comprehensive Nursing Assessment" indicated the following: 1. Patient 6 was alert; oriented to self, place, and time. 2. Patient 6 was able to verbalize needs and concerns. 3. Patient 6 was continent of urine. 4. Patient 6 required ";occasional assistance" but was able to care for most of her personal needs and was able to ambulate with a cane or a walker. During a concurrent interview and record review of Patient 6s medical records on 1/7/2024 at 2:14 PM with DPCS designee (DD), Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, ";CTI," dated 12/13/2024, ";LCD Hospice Eligibility Determination," dated 12/12/2024, and physicians orders were reviewed. DD stated there was no documented evidence that Patient 6 had inability to maintain sufficient fluid and caloric intake with 10% weight loss during the previous 6 months or serum albumin level less than 2.5 gm/dl. DD stated the lack of objective data could lead to Patient 6s inaccurate assessment and would not support Patient 6s eligibility for hospice services. DD stated RN 1 conducted the initial home visit assessment for Patient 6 on 12/12/2024. DD stated Patient was receiving hospice services without a physicians admission order.

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 for two of fourteen sampled patients (Patient 12, and Patient 13). This failure resulted in the hospice claiming reimbursement for patients who did not need hospice care and service management of terminal illness and had the potential of the patients not receiving appropriate healthcare services that could affect their quality of life --- During an interview on 1/10/2025 at 10:20 a.m. with the MD1, MD1 stated he has not seen any patients H&P. MD1 stated he has not spoken or seen any HA patients since being hired in 2023. MD1 stated he receives the patients information from the DPCS. MD1 stated he documents in the physician narrative section of patients CTI based on what the DPCS reports to him. MD1 stated he provides all the admitting, medication, and treatment orders to the DPCS during their interdisciplinary meetings. MD1 was made aware the current HA patients did not have any admitting or treatment orders. MD1 stated, ";I should be more, I should not have been more, I should be more demanding." During an interview on 1/10/2025 at 12:30 p.m. with the Director of Patient Care Services (DPCS), the DPCS stated she based the patients care plans on the initial nursing assessment. During an interview on 1/10/2025 at 3:03pm, with the Administrator (ADM), the ADM stated he knows that all fourteen active patients form the HA do not have admission or treatment orders for hospice services. The ADM stated lately he has not been able to get ahold of the Medical Director 2 (MD2), or the physicians working under him for the orders. 1. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). A review of Patient 12s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. During a record review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #2: Statement for second 90-day period" dated 11/4/2024 to 2/1/2025, indicated ";Due to the patients poor prognosis, worsening comorbidities, and ongoing decline, the patient and family have opted to continue hospice care for comfort measures. The patient meets LCD eligibility criteria for the second benefit period." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 11/4/2024. A review of Patient 12s medical record form titled ";Audit Log" dated from 8/1/2024 to 1/7/2025, indicated MD1 signed Patient 12s CTI dated 11/4/2024 on 11/17/2024. During a review of Patient 12s medical record form titled ";Re-Cert Assessment" dated 11/4/2024, indicated Patient 12s neurological/mental/sensory symptom/demeanor is peaceful, level of consciousness is awake and alert, and oriented to time and person. The form indicated the DPCS narrative documentation included Patient 12s co-morbidities including hypertension (high blood pressure), benign prostatic hyperplasia (BPH, noncancerous enlargement of the prostate gland), and hyperlipidemia (high cholesterol). The DPCS documented narrative also indicated, ";Due to patients poor prognosis, worsening comorbidity and declining condition, patient and family have now opted for hospice care for comfort measures, symptom management and comfort care only. Patient is appropriate for hospice care for the 2nd benefit period per MD order, meeting the criteria for the LCD eligibility." Lastly, the form indicated it was electronically signed by the DPCS on 11/4/2024. A review of Patient 12s medical record form titled ";LCD Hospice Eligibility Determination" dated 11/4/2024, indicated Patient 12s qualifying factors included 1a. a Karnofsky performance status (a number that measures how well a person can perform daily activities) of less than or equal to seventy, 1b. a palliative performance status of less than or equal to seventy, and 2b. pyelonephritis (kidney infection) in the past 12 months. During a concurrent interview and record review on 1/10/2025 at 11:54 a.m. with the Director Of Patient Care Services (DPCS), Patient 12s EMR and physical medical record were reviewed. The DPCS stated Patient 12 does not have any treatment orders. The DPCS stated and verified she completed Patient 12s recertification assessment dated 11/4/2024 and did not receive any hospital documents, images or copy of history and physical from the patient during recertification assessment visit. The DPCS stated the HA did not have Patient 12s history and physical, or any documented evidence that supports her recertification assessment. The DPCS stated there were no physical documents to attest to Patient 12s assessment. The DPCS further stated it is important to have supporting evidence because it supports what is being documented by the SN and objective data is needed to verify patient eligibility for hospice services. 2. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). A review of Patient 13s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. During a record review of Patient 13s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #2: Statement for Second 90-day period" dated 10/31/2024 to 1/28/2025, indicated ";Hospice Medical Director has certified for the 2nd benefit period that the patient has a terminal illness with a life expectancy of six months or less if the disease process will take its normal course." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 10/31/2024. A review of Patient 13s medical record form titled ";Audit Log" dated from 8/1/2024 to 1/7/2025, indicated MD1 signed Patient 13s CTI dated 10/31/2024 on 11/17/2024. During a review of Patient 13s medical record form titled ";Re-cert Assessment" dated 10/31/2024, indicated Patient 13 had edema with a pitting level of 2 but did not indicate the location. The form indicated the DPCSs narrative documentation included Patient 13s co-morbidities including hypertension (high blood pressure), and arthritis (joint pain). The DPCSs documented narrative also indicated, ";Hospice Medical Director has certified for the 2nd benefit period that the patient has a terminal illness with a life expectancy of six months or less if the disease process will take its normal course." Lastly, the form indicated it was electronically signed by the DPCS on 10/31/2024. A review of Patient 13s medical record form titled ";LCD Hospice Eligibility Determination" dated 10/31/2024, indicated Patient 13s qualifying factors included 1c. patient optimally treated for heart disease with diuretics and vasodilators, 2a. the CHF (congestive heart failure, heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling) or angina (chest pain) patient meets the criteria for NYHA Class IV level, 3b. has history of cardiac arrest (heart stopped) or resuscitation, and 3c. has history of unexplained syncope/fainting. During a concurrent interview and record review on 1/10/2025 at 11:54 a.m. with the Director Of Patient Care Services (DPCS), Patient 13s EMR and physical medical record were reviewed. The DPCS stated Patient 13 does not have any treatment orders. The DPCS stated and verified she completed Patient 13s recertification assessment dated 10/31/2024 and did not receive any hospital documents, images or copy of history and physical from the patient during recertification assessment visit. The DPCS stated the HA did not have Patient 13s history and physical, or any documented evidence that supports her recertification assessment. The DPCS stated there were no physical documents to attest to Patient 13s assessment. The DPCS further stated it is important to have supporting evidence because it supports what is being documented by the SN and objective data is needed to verify patient eligibility for hospice services. During a review of the HA's record titled, Job Descriptions for Hospice Medical Director, revised April 2019, indicated "The duties and responsibilities of the Medical Director will include, but not be limited to,the following: 14. Reviewing patients' medical eligibility for hospice services, in accordance with hospiceprogram policies and procedures, and establishing the plan of care in conjunctions withattending physician and interdisciplinary group prior to providing care written certification ofterminal illness 15. Providing written certification of the terminal illness for all subsequent benefit periods".

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 admitting and treatment physician orders were documented in eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13). (Refer to L678). 2. 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 ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13). (Refer to L679). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Clinical Records to ensure patients medical records are safeguarded from unauthorized access by any individuals or hospice staff.

Based on interview and record review the Hospice Agency (HA) failed to ensure patients' clinical records contained documented evidence of physician's orders for admission and treatment for hospice services for eleven of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13). This failure resulted in patients being admitted for hospice services and receiving treatments without a physician order. --- During an interview on 1/10/2025 at 3:03pm, with the Administrator (ADM), the ADM stated he knows that all fourteen active patients form the HA do not have admission or treatment orders for hospice services. The ADM stated lately he has not been able to get ahold of the Medical Director 2 (MD2), or the physicians working under him for the orders. 10. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). A review of Patient 10s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. 11. A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). A review of Patient 11s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. 12. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). A review of Patient 12s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. 13. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). A review of Patient 13s medical record form titled, ";Physician Order" undated, did not indicate there was a physician admission order for hospice services order. 6. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a record review of Patient 6s medical record form titled ";Physicians Order" dated 1/4/2025, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a concurrent interview and record review of Patient 6s medical records on 1/7/2024 at 2:14 PM with DPCS designee (DD), Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, and physicians orders were reviewed. DD stated the lack of objective data could lead to Patient 6s inaccurate assessment and would not support Patient 6s eligibility for hospice services. DD stated RN 1 conducted the initial home visit assessment for Patient 6 on 12/12/2024. DD stated Patient was receiving hospice services without a physicians admission order. 7. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease with heart failure. During a record review of Patient 7s medical record form, titled ";Physicians Order" dated 12/19/2024, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a concurrent interview and record review of Patient 7s medical records on 1/7/2024 at 2:14 PM with DD, Patient 7s ";Comprehensive Nursing Assessment," dated 11/26/2024, and physicians orders were reviewed. DD stated RN 1 conducted the initial home visit assessment for Patient 7 on 11/26/2024. DD stated Patient 7 was receiving hospice services without a physicians admission order. 8. During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease that causes difficulty breathing). During a record review of Patient 8s medical record form, titled ";Physicians Order" dated 12/11/2024, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a review of Patient 8s medical record form, titled ";Comprehensive Nursing Assessment," dated 11/25/2024, the ";Comprehensive Nursing Assessment" indicated Patient 8 was on oxygen therapy at 2 liters per minute via nasal cannula (device that provides supplemental oxygen through the nose). During a concurrent interview and record review of Patient 8s medical records on 1/7/2024 at 2:14 PM with DD, Patient 8s ";Comprehensive Nursing Assessment," dated 11/25/2024, care plans, and physicians orders were reviewed. DD stated there were no hospital records or clinical records prior to hospice admission on file for Patient 8. DD stated RN 1 conducted the initial home visit assessment for Patient 8 on 11/25/2024. DD stated Patient 8 was receiving hospice services without a physicians admission order. DD stated there was no documented evidence of a physicians order for Patient 8s oxygen therapy. DD stated it was important that oxygen therapy was ordered and documented in the plan to ensure all staff was ";on the same page when taking care of the patient," and would know and consistently implement the interventions to determine if effective or not. During an interview on 1/8/2025 at 11:21 a.m., with the Medical Director 2 (MD2), MD 2 stated he does not work for or has heard of the HA. MD2 stated he is not the HAs referring physician. MD2 stated he does not work in Los Angeles County. During an interview on 1/10/2025 at 10:20 a.m. with the MD1, MD1 stated he has not seen any patients H&P. MD1 stated he has not spoken or seen any HA patients since being hired in 2023. MD1 stated he receives the patients information from the DPCS. MD1 stated he documents in the physician narrative section of patients CTI based on what the DPCS reports to him. MD1 stated he provides all the admitting, medication, and treatment orders to the DPCS during their interdisciplinary meetings. MD1 was made aware the current HA patients did not have any admitting or treatment orders. MD1 stated, ";I should be more, I should not have been more, I should be more demanding." During an interview on 1/10/2025 at 12:30 p.m., with the Director of Patient Care Services (DPCS), the DPCS stated she based the patients care plans on the initial nursing assessment. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). Lastly, the form indicated Medical Director 1 (MD1) was listed under ";Medical Director" and Medical Doctor 2 (MD2) was listed under ";Referring/Attending/Patient Choice". During a record review of Patient 1s medical record form titled ";Physician Order" dated 1/4/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 1s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, durable medical equipment (DME), supplies, and lab were left blank. The form also indicated it electronically signed by the DPCS on 12/11/2024. During a record review of Patient 1s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated Registered Nurse 1 (RN1)s narrative documentation included Patient 1s co-morbidities including diabetes (high blood sugar), arthritis (joint pain), scoliosis (abnormal spine curvature), and hypertension (high blood pressure). Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 12:04 p.m. with the Director of Patient Care Services Designee (DD) of Patient 1s Electronic Medical Record (EMR) and physical medical record, the DD stated Patient 1s start of care date was 12/13/2024. The DD stated Patient 1 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 1 was receiving oxygen from the HA without a physicians order. The DD stated Patient 1s diabetes was not being assessed by the HA. The DD stated she did not know if the family was managing Patient 1s diabetes. The DD stated Patient 1 can experience confusion, coma, or death if his blood sugar goes too high or too low. The DD stated diabetes complications can be prevented if managed correctly. During an interview on 1/8/2025 at 10:50 a.m. with RN1, RN1 stated he conducted Patient 1s initial assessment on 12/13/2025 and has seen Patient 1 for two or three visits. RN1 stated he reviews patients medications and if they have medications for diabetes, he asks about it. RN1 stated Patient 1 ";probably" told him what his blood sugar reading was, but RN1 did not document that. RN1 stated he spoke with MD2 about Patient 1 at which time he received verbal orders from MD2. RN1 was unable to provide MD2s phone number. During a concurrent interview and record review on 1/8/2025 at 12:10 p.m. with the DPCS of Patient 1s electronic and physical medical record, the DPCS stated Patient 1 is receiving hospice services without a physician admission order. During an interview on 1/8/2025 at 12:35 p.m. with the ADM of Patient 1s electronic and physical medical record, the ADM stated MD2 was Patient 1s referring doctor and needed to sign the admitting orders. During a concurrent interview and record review on 1/8/2025 at 12:35 p.m. with the DPCS of Patient 1s electronic and physical medical record, the DPCS stated Patient 1 does not have any treatment orders. The DPCS stated there were no physical documents to attest to Patient 1s assessment. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). Lastly, the form indicated MD1 was listed under ";Medical Director" and MD2 was listed under ";Referring/Attending/Patient Choice". During a record review of Patient 2s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 2s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, functional limitations, activities permitted, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed. During a record review of Patient 2s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated RN1s narrative documentation included Patient 2s co-morbidities including diabetes, arthritis, depression, and open-heart surgery. Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 1 p.m. with the DD of Patient 2s electronic and physical medical record, the DD stated Patient 2 did not have admission or treatment physician orders which were needed to be able to treat the patient. During an interview on 1/8/2025 at 10:45 a.m. with License Vocational Nurse 1 (LVN1), LVN1 stated she visited Patient 2 twice. LVN1 stated she does not follow Patient 2s plan of care because she does not have it. LVN1 stated she checks Patient 2s blood pressure, ask when his last bowel movement was, if he is experiencing any medication side effects, if he had any falls, how his sleeping and appetite are, and if there are any changes to report. During a concurrent interview and record review on 1/8/2025 at 12:45 p.m. with the DPCS of Patient 2s electronic and physical medical record, the DPCS stated Patient 2s medical record did not indicate his diabetes was being assessed. The DPCS stated Patient 2 has a risk of going into diabetic ketoacidosis (a metabolic condition that occurs when there is a buildup of ketose in the blood which can be life threatening). 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. Lastly, the form indicated MD1 was listed under ";Medical Director" and MD2 was listed under ";Referring /Attending/Patient Choice". During a record review of Patient 3s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 3s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed. During a record review of Patient 3s medical record form titled ";Comprehensive Nursing Assessment" dated 12/13/2024, indicated RN1s narrative documentation included Patient 3s co-morbidities including diabetes, arthritis, gastritis (stomach pain) and osteoporosis (weak and brittle bones). RN1s documented narrative also included ";The patients current condition, medication, and treatments have been recorded and reviewed with MD via telephone and ordered to continue the medications and treatments upon admission." Lastly, the form indicated it was electronically signed by RN1 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 1:30 p.m. with the DD of Patient 3s electronic and physical medical record, the DD stated Patient 3s diabetes was not being assessed. During a concurrent interview and record review on 1/8/2025 at 1 p.m. with the DPCS of Patient 3s electronic and physical medical record, the DPCS stated Patient 3 is receiving hospice services without a physician admission or treatment orders. 4. During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 11/27/2024 and an end of care date of 12/12/2024 with a primary diagnosis of unspecified cirrhosis of the liver. Lastly, the form indicated MD1 was listed under ";Medical Director" and MD2 was listed under ";Referring/Attending/Patient Choice". During a record review of Patient 5s medical record form titled ";Physician Order" dated 12/19/2025, did not indicate there were physician admission or treatment orders. During a record review of Patient 5s medical record form titled ";Comprehensive Nursing Assessment" dated 11/27/2024, indicated RN1s narrative documentation included Patient 5s co-morbidities including anemia (low iron level in the blood) and osteoporosis (brittle bones). Lastly, the form indicated it was electronically signed by RN1 on 11/27/2024. During a record review of Patient 5s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it was electronically signed by the DPCS on 12/11/2024. During a concurrent interview and record review on 1/8/2025 at 1:10 p.m. with the DPCS of Patient 5s electronic and physical medical record, the DPCS stated Patient 5 did not have psychosocial assessment. The DPCS stated the HA conducted one IDG meeting for Patient 5 dated 12/11/2024. The DPCS stated the MSW and SC did not see Patient 5 therefore were unable to contribute to the IDG meeting discussion. The DPCS stated Patient 5s IDG meeting documentation is missing the MSW and SC signatures because they did not attend the meeting.

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 ten of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 6, Patient 7, Patient 8, Patient 10, Patient 11, Patient 12, and Patient 13). This failure had the potential to result in inaccurate patient information or assessment will be entered in the patients clinical record that could affect the patients quality of care and well-being. --- 7. A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). A review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefit- Statement for first 90-day period" dated 11/19/2024, indicated Registered Nurse 1 (RN 1) obtained verbal authorization from the Medical Director 2 (MD 2) to admit Patient 10 for hospice services. The form also indicated it was not signed by the MD2 and it did not state if MD2 wanted to follow Patient 10s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 10s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 11/19/2024 to 2/16/2025, indicated ";Given her comorbidities and terminal diagnosis, she qualifies for hospice care to manage symptoms and provide comfort. Certification for hospice care is recommended based on her terminal condition and current functional status." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 11/19/2024. A review of Patient 10s medical record form titled ";Audit Log" dated from 11/1/2024 to 1/7/2025, indicated MD1 signed Patient 10s CTI dated 11/19/2024 on 12/13/2024. During a concurrent interview and record review on 1/7/2025 at 3:45 p.m. with the Director of Patient Care Services Designee (DD), Patient 10s Electronic Medical Record (EMR) and physical medical record were reviewed. The DD stated Patient 10 was referred by MD2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 10 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 10s medical records did not contain her history and/or physical, or hospital records therefore, the Hospice Agency (HA) does not have any evidence to support Patient 10s documented LCD. During a concurrent interview and record review on 1/7/2025 at 3:45 pm with the DD, Patient 10s medical record titled History of POC/IDG was reviewed. Patient 10s record indicated the following: - POC/IDG, Initial, dated 11/27/2024 with signatures of the Medical Director (MD) and DPCS, no signatures of the Medical Social Worker (MSW) and Spiritual Counselor (SC). - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and the DPCS, no signatures of the MSW and SC. The DD stated and confirmed Patient 10s POC/IDG dated 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated it is important to have a signature of all IDG members on the POC/IDG to validate their attendance in the meeting, and all members are aware of covering all the needs of the patient holistically. During a concurrent interview and record review on 1/10/2025 at 1:06pm with the DPCS, Patient 10s medical record titled, Audit Log, dated from 11/1/2024 to 1/7/2025 was reviewed. The DPCS stated and verified that the MD1 documented and signed Patient 10s CTI twenty-four days past the indicated date documented on the CTI. The DPCS stated it is important for the MD1 to document his findings on the same day to verify patients hospice eligibility and recall all the findings. 8. A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). A review of Patient 11s medical record form titled ";Physicians Certification for Hospice Benefit- Statement for first 90-day period" dated 11/6/2024, indicated the Skilled Nurse (SN) obtained verbal authorization from the Medical Director 2 (MD 2) to admit Patient 11 for hospice services. The form also indicated it was not signed by the MD2 and it did not state if MD2 wanted to follow Patient 11s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 11s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 11/6/2024 to 2/3/2025, indicated ";Due to the progression of atherosclerotic heart disease, worsening comorbidities, and overall decline in health, the patient meets LCD eligibility for hospice care." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 11/6/2024. A review of Patient 11s medical record form titled ";Audit Log" dated from 11/1/2024 to 1/7/2025, indicated MD1 signed Patient 11s CTI dated 11/6/2024 on 11/17/2024. During a concurrent interview and record review on 1/7/2025 at 4:00 p.m. with the Director of Patient Care Services Designee (DD), Patient 11s Electronic Medical Record (EMR) and physical medical record were reviewed. The DD stated Patient 11 was referred by MD 2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 11 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 11s medical records did not contain her history and/or physical, or hospital records therefore, the Hospice Agency (HA) does not have any evidence to support Patient 11s documented LCD. During a concurrent interview and record review on 1/7/2025 at 4:00 pm with the DD, Patient 11s medical record titled History of POC/IDG was reviewed. Patient 11s record indicated the following: - POC/IDG, Initial, dated 11/13/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 11s POC/IDGs dated 11/13/2024, 11/27/2024, and 12/11/2924 were missing IDG member signatures and were incomplete. The DD stated it is important to have all members of the IDG present and sign the IDG to show their presence and provide coordination of care amongst all disciplines. During a concurrent interview and record review on 1/10/2025 at 1:06pm with the DPCS, Patient 11s medical record titled, Audit Log, dated from 11/1/2024 to 1/7/2025 was reviewed. The DPCS stated and verified that the MD1 documented and signed Patient 11s CTI eleven days past the indicated date documented on the CTI. The DPCS stated it is important for the MD1 to document his findings on the same day to verify patients hospice eligibility and recall all the findings. During a concurrent interview and record review on 1/10/2025 at 3:32pm with the Administrator (ADM), Patient 11s EMR and physical medical record were reviewed. The ADM stated and verified Patient 11 did not have a referral from a physician, clinic, or hospital to the Hospice Agency (HA). 9. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). A review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefit- Statement for first 90-day period" dated 8/6/2024, indicated Registered Nurse 1 (RN 1) obtained verbal authorization from the Medical Director 2 (MD 2) to admit Patient 12 for hospice services. The form also indicated it was not signed by the MD2 and it did not state if MD2 wanted to follow Patient 12s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 12s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #2: Statement for second 90-day period" dated 11/4/2024 to 2/1/2025, indicated ";Due to the patients poor prognosis, worsening comorbidities, and ongoing decline, the patient and family have opted to continue hospice care for comfort measures. The patient meets LCD eligibility criteria for the second benefit period." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 11/4/2024. A review of Patient 12s medical record form titled ";Audit Log" dated from 8/1/2024 to 1/7/2025, indicated MD1 signed Patient 12s CTI dated 11/4/2024 on 11/17/2024. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the Director of Patient Care Services Designee (DD), Patient 12s Electronic Medical Record (EMR) and physical medical record were reviewed. The DD stated Patient 12 was referred by MD2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 12 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 12s medical records did not contain her history and/or physical, or hospital records therefore, the Hospice Agency (HA) does not have any evidence to support Patient 12s documented LCD. During a concurrent interview and record review on 1/7/2025 at 4:15 p.m. with the DD, Patient 12s medical record titled History of POC/IDG was reviewed. Patient 12s record indicated the following: - POC/IDG, Initial, dated 8/7/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 8/21/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 9/4/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/18/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/2/2024 with signatures of the MD and the DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 10/16/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/30/2024 with signatures of the MD and the DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/13/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 12s POC/IDGs dated 9/4/2024, 9/18/2024, 10/2/2024, 10/16/2024, 10/30/2024, 11/13/2024, 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated the importance of all IDG members to be present, complete and sign the patients IDG is to be able to review the POC together, be on the same page about the patients care and update as needed. During a concurrent interview and record review on 1/10/2025 at 1:06pm with the DPCS, Patient 12s medical record titled, Audit Log, dated from 8/1/2024 to 1/7/2025 was reviewed. The DPCS stated and verified that the MD1 documented and signed Patient 12s CTI thirteen days past the indicated date documented on the CTI. The DPCS stated it is important for the MD1 to document his findings on the same day to verify patients hospice eligibility and recall all the findings. During a concurrent interview and record review on 1/10/2025 at 3:32pm with the Administrator (ADM), Patient 12s EMR and physical medical record were reviewed. The ADM stated and verified Patient 12 did not have a referral from a physician, clinic, or hospital to the Hospice Agency (HA). 10. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). A review of Patient 13s medical record form titled ";Physicians Certification for Hospice Benefit- Statement for first 90-day period" dated 8/2/2024, indicated Registered Nurse 1 (RN 1) obtained verbal authorization from the Medical Director 2 (MD 2) to admit Patient 13 for hospice services. The form also indicated it was not signed by the MD2 and it did not state if MD2 wanted to follow Patient 13s care or not. Lastly, the form indicated ";It is my clinical judgement that this patient has a life expectancy of six months or less if the terminal illness runs its normal course. My signature constitutes approval to admit to hospice." During a record review of Patient 13s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #2: Statement for Second 90-day period" dated 10/31/2024 to 1/28/2025, indicated ";Hospice Medical Director has certified for the 2nd benefit period that the patient has a terminal illness with a life expectancy of six months or less if the disease process will take its normal course." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by the Medical Director 1 (MD 1) on 10/31/2024. A review of Patient 13s medical record form titled ";Audit Log" dated from 8/1/2024 to 1/7/2025, indicated MD1 signed Patient 13s CTI dated 10/31/2024 on 11/17/2024. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m. with the Director of Patient Care Services Designee (DD), Patient 13s Electronic Medical Record (EMR) and physical medical record were reviewed. The DD stated Patient 13 was referred by MD2 but that the referral did not have MD2s signature to authenticate the referral. The DD stated Patient 13 did not have admission or treatment physician orders which were needed to be able to treat the patient. The DD stated Patient 13s medical records did not contain her history and/or physical, or hospital records therefore, the Hospice Agency (HA) does not have any evidence to support Patient 13s documented LCD. During a concurrent interview and record review on 1/7/2025 at 4:25 p.m. with the D), Patient 13s medical record titled History of POC/IDG was reviewed. Patient 13s record indicated the following: - POC/IDG, Initial, dated 8/7/2024 with signatures of the MD, DPCS and MSW, no signature of the SC. - POC/IDG, Updated, dated 8/21/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/4/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 9/18/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/2/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/16/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 10/30/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 11/13/2024 with signatures of the MD and DPCS, no signature of the MSW, and SC. - POC/IDG, Updated, dated 11/27/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. - POC/IDG, Updated, dated 12/11/2024 with signatures of the MD and DPCS, no signatures of the MSW, and SC. The DD stated and confirmed Patient 13s POC/IDGs dated 8/7/2024, 8/21/2024, 9/4/2024, 9/18/2024, 10/2/2024, 10/16/2024, 10/30/2024, 11/13/2024, 11/27/2024 and 12/11/2024 were missing IDG member signatures and were incomplete. The DD stated the importance of all members of the IDG keep up with the meetings, and complete and sign the POC/IDG is to make sure the patients needs, like safety, care, medications, emotional/spiritual, and eligibility are being updated. During a concurrent interview and record review on 1/10/2025 at 1:06pm with the DPCS, Patient 13s medical record titled, Audit Log, dated from 8/1/2024 to 1/7/2025 was reviewed. The DPCS stated and verified that the MD1 documented and signed Patient 13s CTI seventeen days past the indicated date documented on the CTI. The DPCS stated it is important for the MD1 to document his findings on the same day to verify patients hospice eligibility and recall all the findings. During a concurrent interview and record review on 1/10/2025 at 3:32pm with the Administrator (ADM), Patient 13s EMR and physical medical record were reviewed. The ADM stated and verified Patient 13 did not have a referral from a physician, clinic, or hospital to the Hospice Agency (HA). 4. During a record review of Patient 6s medical record form, titled ";Personal Information", the ";Personal Information" indicated SOC date of 12/12/2024, with a primary diagnosis of Alzheimers Disease (brain disorder that affects memory and thinking skills and interferes with daily tasks). During a record review of Patient 6s medical record form, titled ";Physicians Certification for Hospice Benefit – Statement for First 90-day period," dated 12/12/2024, indicated RN 1 obtained verbal authorization from the MD 2 to admit Patient 6 for hospice services. The form indicated MD 2 did not sign the form. The form did not indicate if MD 2 wanted to follow Patient 6s care or not. Lastly, the form indicated, ";It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice." During a record review of Patient 6s medical record form, titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for First 90-day period," dated 12/12/2024 to 3/11/2025, indicated Patient 6 ";has a life expectancy of 6 months or less, if the terminal illness, runs its normal course." The form also indicated, ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by MD 1 on 12/13/2024. During a record review of Patient 6s medical record form titled ";Audit Log" dated from 12/12/2024 to 1/7/2025, indicated MD 1 signed Patient 6s CTI dated 12/12/2024 on 3/11/2025 on 12/26/2024. During a record review of Patient 6s medical record form, titled ";Comprehensive Nursing Assessment," dated 12/12/2024, the ";Comprehensive Nursing Assessment" indicated the Director of Patient Care Services (DPCS) signed the form on 1/2/2025. During a record review of Patient 6s medical record form titled ";Audit Log" dated from 12/12/2024 to 1/10/2025, indicated RN 1 created Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, on 12/23/2024. During a record review of Patient 6s medical record form, titled ";Physician Orders for Life-Sustaining Treatment (POLST), dated 12/12/2024, the POLST indicated it was a ";Physician Order Sheet based on the persons current medical condition and wishes." The POLST indicated no physician signed the Patient 6s form. The POLST indicated Patient 6 wishes: ";Do Not Attempt Resuscitation (DNR, allow natural death)," ";Comfort Measures Only," and ";No artificial nutrition by tube." During a concurrent interview and record review of Patient 6s medical records on 1/7/2024 at 2:14 PM with DD Patient 6s ";Comprehensive Nursing Assessment," dated 12/12/2024, and physicians orders were reviewed. DD stated there was no documented evidence that Patient 6 had inability to maintain sufficient fluid and caloric intake with 10% weight loss during the previous 6 months or serum albumin level less than 2.5 gm/dl. DD stated RN 1 conducted the initial home visit assessment for Patient 6 on 12/12/2024 but the notes were uploaded on 12/23/2024. DD stated Patient 6 was receiving hospice services without a physicians admission order. DD stated the Patient 6s POLST was not considered ";valid" due to missing physicians signature. DD stated the licensed nurse must then go against Patient 6s wishes and perform full treatment, including resuscitation, in case Patient 6 did not have pulse and was not breathing. During an interview on 1/10/2024 at 11:57 AM, the DPCS stated it was important to document and upload in the patients electronic health records the visit notes and comprehensive assessments within 24-48 hours to ensure accuracy of documentation and continuity of care. 5. During a record review of Patient 7s medical record form, titled ";Personal Information," the ";Personal Information" indicated SOC date of 11/26/2024, with a primary diagnosis of hypertensive heart disease (long-term heart problems due to high blood pressure) with heart failure. During a record review of Patient 7s medical record form, titled ";Physicians Order" dated 12/19/2024, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 7s medical record form, titled ";Physicians Certification for Hospice Benefit – Statement for First 90-day period," dated 11/26/2024, indicated RN 1 obtained verbal authorization from the MD 2, to admit Patient 7 for hospice services. The form indicated MD 2 did not sign the form. The form did not indicate if MD 2 wanted to follow Patient 7s care or not. Lastly, the form indicated, ";It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice." During a record review of Patient 7s medical record form, titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for First 90-day period," dated 11/26/2024 to 2/23/2025, indicated Patient 7 ";has a life expectancy of 6 months or less, if the terminal illness, runs its normal course." The form also indicated, ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by MD 1 on 11/26/2024. During a record review of Patient 7s medical record form, titled ";Audit Log" dated from 11/26/2024 to 1/7/2025, indicated MD 1 signed Patient 7s CTI, dated 11/26/2024, on 12/13/2024. During a record review of Patient 7s medical record form, titled ";Comprehensive Nursing Assessment," dated 11/26/2024, the ";Comprehensive Nursing Assessment" indicated Registered Nurse 1 (RN 1) signed the form on 11/26/2024. During a record review of Patient 7s medical record form titled ";Audit Log" dated from 11/26/2024 to 1/10/2025, indicated RN 1 signed Patient 7s ";Comprehensive Nursing Assessment" dated 11/26/2024, on 12/2/2024. During a record review of Patient 7s medical record form, titled ";Physician Orders for Life-Sustaining Treatment (POLST), dated 11/26/2024, the POLST indicated it was a ";Physician Order Sheet based on the persons current medical condition and wishes." The POLST indicated no physician signed the Patient 7s form. The POLST indicated Patient 7 wishes: ";Do Not Attempt Resuscitation (DNR, allow natural death)," ";Comfort Measures Only," and ";No artificial nutrition by tube." During a record review of Patient 7s medical record form, titled ";History of POC/IDG (undated)," the ";History of POC/IDG" indicated IDG was conducted for Patient 7 on 11/27/2024 and 12/11/2024. During a concurrent interview and record review of Patient 7s medical records on 1/7/2024 at 2:14 PM with DD, Patient 7s ";Comprehensive Nursing Assessment," dated 11/26/2024, ";POC/IDG Review," dated 11/27/2024 and 12/11/2024, and physicians orders were reviewed. DD stated RN 1 documented that Patient 7 met the criteria for NYHA Class IV level but lacked documented evidence to support Patient 7s eligibility for hospice services. DD stated RN 1 conducted the initial home visit assessment for Patient 7 on 11/26/2024 but the notes were uploaded on 12/2/2024. DD stated Patient 7 was receiving hospice services without a physicians admission order. DD stated the Patient 7s POLST was not considered ";valid" due to missing physicians signature. DD stated the licensed nurse must then go against Patient 7s wishes and perform full treatment, including resuscitation, in case Patient 7 did not have pulse and was not breathing. DD stated the MSW and Chaplain did not sign ";POC/IDG Review," dated 11/27/2024 and 12/11/2024. During an interview on 1/10/2025 at 11:57 AM, the Director of Patient Care Services (DPCS) stated the IDG last conducted the virtual meeting on 12/11/2024. The DPCS stated MSW has not attended any IDG meeting since ";4-5 months ago." The DPCS stated she has not seen the Chaplain virtually or in-person. The DPCS stated the MSW and Chaplain did not attend the IDG meeting if they did not sign the ";POC/IDG Review." The DPCS stated MDS was responsible for assessing Patient 7s emotional, socioeconomic, and mental aspect of the patient to be able to provide holistic care. The DPCS stated the Chaplain was responsible for providing Patient 7 spiritual comfort. 6.During a record review of Patient 8s medical record form, titled ";Personal Information", the ";Personal Information" indicated an SOC date of 11/25/2024, with a primary diagnosis of chronic obstructive pulmonary disease (COPD, long-term lung disease that causes difficulty breathing). During a record review of Patient 8s medical record form, titled ";Physicians Order" dated 12/11/2024, the ";Physicians Order" did not indicate there was a physician admission order for hospice services. During a record review of Patient 8s medical record form, titled ";Physicians Certification for Hospice Benefit – Statement for First 90-day period," dated 11/25/2024, indicated RN 1 obtained verbal authorization from the MD 2 to admit Patient 8 for hospice services. The form indicated MD 2 did not sign the form. The form did not indicate if MD 2 wanted to follow Patient 8s care or not. Lastly, the form indicated, ";It is my clinical judgment that this patient has a life expectancy of six months or less, if the terminal illness runs its normal course. My signature constitutes approval to admit to Hospice." During a record review of Patient 8s medical record form, titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for First 90-day period," dated 11/25/2024 to 2/22/2025, indicated Patient 8 ";has a life expectancy of 6 months or less, if the terminal illness, runs its normal course." The form also indicated, ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by MD 1 on 11/25/2024. During a record review of Patient 8s medical record form, titled ";Audit Log" dated from 11/25/2024 to 1/7/2025, indicated MD 1 signed Patient 8s CTI, dated 11/25/2024, on 12/13/2024. During a record review of Patient 8s medical record form, titled ";Comprehensive Nursing Assessment," dated 11/25/2024, the ";Comprehensive Nursing Assessment" indicated RN 1 electronically signed the form on 11/25/2024. During a record review of Patient 8s medical record form titled ";Audit Log" dated from 11/25/2024 to 1/7/2025, indicated RN 1 signed Patient 7s ";Comprehensive Nursing Assessment" dated 11/25/2024, on 12/2/2024. During a record review of Patient 8s medical record form, titled ";Physician Orders for Life-Sustaining Treatment (POLST), dated 11/25/2024, the POLST indicated it was a ";Physician Order Sheet based on the persons current medical condition and wishes." The POLST indicated no physician signed the Patient 8s form. The POLST indicated Patient 8 wishes: ";Do Not Attempt Resuscitation (DNR, allow natural death)," ";Comfort Measures Only," and ";No artificial nutrition by tube." During a concurrent interview and record review of Patient 8s medical records on 1/7/2024 at 2:14 PM with DD, Patient 8s ";Comprehensive Nursing Assessment," dated 11/25/2024, ";POC/IDG Review," dated 11/27/2024 and 12/11/2024, and physicians orders were reviewed. DD stated RN 1 documented Patient 8 had ";hypoxemia at rest on room air, but there was no documented evidence of pO2 in Patient 8s medical records. DD stated RN 1 conducted the initial home visit assessment for Patient 8 on 11/25/2024 but RN 1 uploaded the notes on 12/2/2024. DD stated Patient 8 was receiving hospice services without a physicians admission order. DD stated the Patient 8s POLST was not considered ";valid" due to missing physicians signature. DD stated the licensed nurse must then go against Patient 8s wishes and perform full treatment, including resuscitation, in case Patient 8 did not have pulse and was not breathing. DD stated the IDG meetings for Patient 8 were only conducted on 11/27/2024 and 12/11/2024.DD stated the MSW and Chaplain did not sign ";POC/IDG Review," dated 11/27/2024 and 12/11/2024. During an interview on 1/10/2025 at 11:57 AM, the Director of Patient Care Services (DPCS) stated the IDG last conducted the virtual meeting on 12/11/2024. The DPCS stated MSW has not attended any IDG meeting since ";4-5 months ago." The DPCS stated she has not seen the Chaplain virtually or in-person. The DPCS stated the MSW and Chaplain did not attend the IDG meeting if they did not sign the ";POC/IDG Review." The DPCS stated MDS was responsible for assessing Patient 8s emotional, socioeconomic, and mental condition to be able to provide holistic care. The DPCS stated the Chaplain was responsible for providing Patient 8s spiritual comfort. During an interview on 1/10/2025 at 10 a.m. with the MD1, MD1 stated patients Certification of Terminal Illness (CTI- a brief narrative designed to explain clinical findings that support a life expectancy of six months or less which is composed by the hospice physician) should be signed as soon as it is composed. The MD1 stated he sometimes signs patients CTIs late. The MD1 stated his signature on the patients CTIs would indicate his authentication that he (MD1) composed and signed the CTIs. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). During a record review of Patient 1s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 12/13/2024 to 3/12/2025, indicated ";In my professional opinion that the patient has a prognosis of less than six months based on his current clinical condition and the trajectory of his illness." The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by MD1 on 12/16/2024. During a record review of Patient 1s medical record form titled ";Audit Log" dated from 11/26/2024 to 1/7/2025, indicated the Medical Director 1 (MD1) signed Patient 1s CTI dated 12/13/2024 on 12/20/2024. 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). During a record review of Patient 2s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 12/13/2024 to 3/12/2025, indicated Patient 2 co morbidities include arthritis, diabetes, chronic back pain, and depression. The form also indicated Patient 2 suffers from dyspnea, chest pain and reduced capacity for physical activity, and discomfort even at rest. The form also indicated ";I attest/confirm that I composed this narrative based on my review of patients medical record, team assessment and/or examination of the patient." Lastly, the form indicated it was electronically signed by MD1 on 12/16/2024. During a record review of Patient 2s medical record form titled ";Audit Log" dated from 12/15/2024 to 1/7/2025, indicated the MD1 signed Patient 2s CTI dated 12/13/2024 on 12/26/2024. During a record review of Patient 2s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, functional limitations, activities permitted, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed. 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. During a record review of Patient 3s medical record form titled ";Physicians Certification for Hospice Benefit – Certification #1: Statement for first 90-day period" dated 12/13/2024 to 3/12/2025, indicated ";This patients terminal diagnosis of COPD is accompanied by significant comorbidities and functional decline. Her symptoms including shortness of breath, pain and edema are being addressed with ongoing hospice care. Her prognosis is poor, and hospice care remains appropriate for symptom management and comfort care." Lastly, the form indicated it was electronically signed by MD1 on 12/16/2024. During a record review of Patient 3s medical record form titled ";Audit Log" dated from 12/1/2024 to 1/7/2025, indicated the MD1 signed Patient 3s CTI dated 12/13/2024 on 12/26/2024. During a record review of Patient 3s medical record form titled ";POC Summary" dated as of 1/7/2025, indicated it was not complete. Sections allergies, diet, treatment, other, DME, supplies, and lab were left blank. The form also indicated it did not identify who the author was because it was not signed.

Based on interview and record review the Hospice Agency (HA) failed to ensure the Condition of Participation for Personnel Qualification was met as evidence by the following: --- 1. The HA failed to provide documented evidence their licensed professionals were qualified and licensed to provide patient care for thirteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). (Refer to L784). 2. The HA failed to provide evidence criminal background checks were done for their staff before providing care and services for thirteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) (Refer to L795). The cumulative effect of these systemic practices resulted in the failure of the hospice to deliver statutorily mandated compliance with Federal regulations for Personnel Qualification to ensure patients were being cared for by qualified personnel.

Based on interview and record review the Hospice Agency (HA) failed to provide evidence their licensed professionals were qualified and licensed to provide patient care for thirteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in patients being taken care of unqualified and unlicensed staff that could affect the health and safety of these patients. --- 10.A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). 11. A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). 12. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). 13. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). 14. A review of Patient 14s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 7/20/2023, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years), and an End of Care (EOC) date of 8/14/2023. During a concurrent interview and record review on 1/10/2025 at 1:10 PM with the Director of Patient Care Services (DPCS), the employee files of HA were reviewed. The DPCS stated the following: 1. There was no documented evidence that RN 1, RN 2, and Licensed Vocational Nurse 1 (LVN 1) had any Skills Competency validation prior to conducting skilled nursing visits to the HA patients. DPCS stated the HA must conduct Skills Competency Validation for licensed nurses upon hire and annually to ensure they are able to perform the job duties related to providing patient care. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. 4. During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 11/27/2024 and an end of care date of 12/12/2024 with a primary diagnosis of unspecified cirrhosis of the liver.

Based on interview and record review the Hospice Agency (HA) failed to provide evidence criminal background checks were done for their staff before providing care and services for thirteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14). This failure had the potential to result in patients being taken care of by an unqualified individual that could affect the health and safety of these hospice patients. --- 10.A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). 11. A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). 12. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). 13. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). 14. A review of Patient 14s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 7/20/2023, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years), and an End of Care (EOC) date of 8/14/2023. During a concurrent interview and record review on 1/10/2025 at 1:10 PM with the Director of Patient Care Services (DPCS), the employee files of HA were reviewed. The DPCS stated the following: 1. There was no documented evidence that RN 1, RN 2, and Licensed Vocational Nurse 1 (LVN 1) had any Skills Competency validation prior to conducting skilled nursing visits to the HA patients. DPCS stated the HA must conduct Skills Competency Validation for licensed nurses upon hire and annually to ensure they are able to perform the job duties related to providing patient care. 2. DPCS stated she did not have any training as DPCS. DPCS stated background checks were not done for RN 1, RN 2, LVN 1, DPCS, and Medical Director. DPCS stated it was important to conduct background checks prior to hiring a prospective employee to ensure the safety of the patients. 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. 4. During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 11/27/2024 and an end of care date of 12/12/2024 with a primary diagnosis of unspecified cirrhosis of the liver.

Based on observation, interview, and record review, the Hospice Agency (HA) failed to notify State Department of a change of location (CHOL), change of ownership (CHOW), and change of Administrator (ADM) and Director of Patient Care Services (DPCS). This failure resulted in the HA providing services for thirteen of fourteen sampled patients (Patient 1, Patient 2, Patient 3, Patient 5, Patient 6, Patient 7, Patient 8, Patient 9, Patient 10, Patient 11, Patient 12, Patient 13, and Patient 14) from an unknown location and or unapproved geographic service areas (GSA). --- 10.A review of Patient 10s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 11/19/2024, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years). 11. A review of Patient 11s ";Personal Information", document indicated an SOC of 11/6/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery with unstable angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow and causing chest pain). 12. A review of Patient 12s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/6/2024, with a terminal diagnosis of Alzheimers disease with early onset (a brain disorder that causes memory loss, confusion, and difficulty thinking). 13. A review of Patient 13s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 8/2/2024, with a terminal diagnosis of atherosclerotic heart disease of native coronary artery without angina pectoris (buildup of fatty material called plaque along the walls of the arteries causing them to be narrow, reducing blood flow). 14. A review of Patient 14s medical record form titled ";Personal Information", indicated a Start of Care (SOC) date of 7/20/2023, with a terminal diagnosis of hypertensive heart disease with heart failure (a serious condition that occurs when high blood pressure damages the heart over many years), and an End of Care (EOC) date of 8/14/2023. During a concurrent interview and observation on 1/6/2025 at 12:15 p.m. arrived at HAs address on file with the Department. Building suite was access, HAs name was posted on suite door, but it did not list the HAs phone number. Buildings Manager (BM) stated she had not seen HA staff. BM provided HAs contact phone number. During an observation on 1/6/2025 at 12:50 p.m. arrived at address provided on complaint form. Building was accessed. Business directory did not list the HAs information. On 1/6/2025 at 12:55 p.m., HAs phone number on file with the Department was called. Automated message stated, ";You qualify to receive a retail offer...". On 1/6/2025 at 12:57 p.m., HAs phone number provided by BM was called. A man's voice answered and was asked if this was the HAs phone number. The person who answered the phone stated it was not and hang up the phone call. On 1/6/2025 at 12:58 p.m., Department Supervisor was called. DS was asked to provide any phone numbers listed under the HAs profile with the Department. On 1/6/2025 at 1:01 p.m., the phone number provided by the DS was called with no answer. Message with call back number left. On 1/6/2025 at 1:16 p.m., the phone number provided by the DS was called with no answer. Message with call back number left. During an interview on 1/6/2025 at 1:37 p.m., with the HAs Administrator (ADM), to the phone number provided by the DS was made. The ADM stated he was the HAs ADM. The ADM stated the HAs address on file has not been used by the HA for the past year. The ADM stated the HA had been operating on the address found on the complaint form for a year, suite 303. The ADM stated the Centers for Medical and Medicare (CMS) were notified of the change of address and ownership. During an interview on 1/7/2025 at 2:47 p.m., with the ADM, the ADM stated he became the HAs owner and Administrator in 2023. The ADM stated the HA has been operating in the new address (address not on the Department file) since 2023. The ADM stated that Department was notified by the Consulting Group (CG). On 1/7/2025 at 3:49 p.m., the ADM was requested to provide evidence of the submitted change of location and ownership application made to the CMS. During an interview on 1/10/2025 at 3 p.m., with the ADM, the ADM stated he was waiting for the CG to send any information regarding the CMS notification of the change of location and owner. The ADM stated it was important for the State Department to be aware of the HAs change of location and owner to assure the HA is in compliance. The ADM stated it was important for the State Department to be aware of the HAs owner and ADM contact information. The ADM the HA had a new acting Director of Patient Care Services but was unable to change the HAs profile information because he was not listed as the HAs owner/ADM yet. The ADM stated the Department needed to know the new information to know that the HA has a ";new foundation with the right staff". 1. During a record review of Patient 1s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing). 2. During a record review of Patient 2s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of atherosclerosis heart disease of native coronary artery with unstable angina pectoris (plaque buildup in the arteries of the heart causing blood flow disruption and pain). 3. During a record review of Patient 3s medical record form titled ";Personal Information" indicated a start of care date of 12/13/2024 with a primary diagnosis of chronic obstructive pulmonary disease. 4. During a record review of Patient 5s medical record form titled ";Personal Information" indicated a start of care date of 11/27/2024 and an end of care date of 12/12/2024 with a primary diagnosis of unspecified cirrhosis of the liver.

Upon observation, there was no evidence the Emergency Plan communication plan includes all of the following: • Names and contact information for the following: • Hospice employees There was no evidence of name and contact information for Hospice employees. Corrected on site.

Upon patient record review, 5 of 5 records (Patient #1, #2, #3, #4, #5) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patients 1, 2, 3, 4, 5: PER SOC SN assessment Pt is high fall risk, gait and ambulatory disturbance, increased weakness, decreased muscle strength, decreased ROM, requires maximum assistance with ambulation. The POC states Fall prevention under musculoskeletal. HHA POC includes pt. is prone to fractures. There was no evidence of fall precautions on the HHA POC.

Upon observation, there was no evidence a copy is provided of the hospice written policies and procedures on the management and disposal of controlled drugs to the patient or patient representative and family. There was no evidence within the admission file/Patient handbook, or in the three home visit hospice files in their homes of a copy of the written policies and procedures on the management and disposal of controlled drugs.

Upon client record review, 5 of 5 records (Patient #1, #2, #3, #4, #5) did not have evidence that the written policies and procedures for managing controlled drugs was provided and discussed. Patients 1, 2, 3, 4, 5: Per policy 4-054.1 The admitting nurse/case manager will document in the clinical record that the patient and family/caregiver were given the written policies and procedures for managing controlled drugs and discussed the disposal of medications and took responsibility to do so. There was no evidence of this documentation.